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COPYRIGHT DEPOSIT. 



URINARY 

ANALYSIS AND DIAGNOSIS 



BY MICROSCOPICAL AND CHEMICAL 
EXAMINATION 



LOUIS HEITZMANN, M.D. 

u 

NEW YORK 

FORMERLY PROFESSOR OF PATHOLOGY AND BACTERIOLOGY, 

FORDHAM UNIVERSITY SCHOOL OF MEDICINE, 

FORDHAM, NEW YORK, N. Y. 



Tourtl) Revised an6 "Enlarged €6itioa 



WITH ONE HUNDRED AND THIRTY-ONE ILLUSTRATIONS,. 
MOSTLY ORIGINAL 



NEW YORK 

WILLIAM WOOD AND COMPANY 

1921 




S2> 



Copyright, 1921 
By WILLIAM WOOD & COMPANY 



M 20 m\ 



"THE MAPLE PRESS YORK PA 



©CI.A617400 



S\AS> 






Go tbe rtfcemorE 

OF 

MY FATHER 
CARL HEITZMANtf, M.D. 

WHOSE LIFE-WORK WAS DEVOTED 

TO THE 

SCIENCE OF MEDICINE 

THIS VOLUME IS AFFECTIONATELY 

Deoicateo 



PREFACE TO THE FOURTH EDITION 



In the preparation of the present edition of this work, the general 
plan of the previous editions has been adhered to. No extensive 
changes have been found necessary, but the text has been thoroughly 
revised. New chemical tests, which have proven useful and of 
practical value, have been added. In the part devoted to micro- 
scopical examination some portions have been enlarged, others 
entirely rewritten, and a few old illustrations have been replaced by 
new drawings. 

As before, the book is intended as a purely practical one, and the 
first part on the chemical examination makes no claims for com- 
pleteness. Only those tests are given, which can be used with advan- 
tage and without the necessity of a completely equipped chemical 
laboratory, by the general laboratory worker and by the practitioner, 
who desires to do his own examinations, or to have a practical knowl- 
edge of urinary analysis. 

A careful microscopical examination of the urinary sediment is 
of infinite value to the practicing physician in helping him at arriving 
at correct diagnoses in many doubtful cases, and is frequently of 
much greater value than the most painstaking chemical examination. 
This book aims, both by the text and the illustrations, to be of aid 
in this important topic of clinical pathology. 

The last chapter on the Determination of the Functional Efficiency 
of the Kidneys has been written for this edition by Dr. Walter T. 
Dannreuther, to whom the author wishes to express his most grateful 
appreciation. 

Louis Heitzmann. 
New York City, April, 1921, 
38 West 90th Street. 



PREFACE TO THE THIRD EDITION 



Since the appearance of the last edition of this work 3 many ad- 
vances have been made in the chemical analysis of urine, while micro- 
scopical examination and especially microscopical diagnosis still 
receive comparatively scant attention in most text-books on this 
subject. Many years of experience and teaching have shown the 
author that correct diagnoses by means of microscopical examina- 
tion of urine can frequently be made in cases where other methods 
are of little or no practical value. 

In the present revision of this work, the aim has again been to 
increase and improve the first part on chemical examination, and to 
incorporate in it all the simpler methods and tests which have proven 
of value as an aid to urinary diagnosis in the hands of different authors. 
Many new tests have been added, and this part has been considerably 
enlarged, though it makes no claim for completeness. With few ex- 
ceptions the more complicated tests, which can only be carried out in 
completely fitted chemical laboratories have, as before, been omitted.. 

As in the previous editions, the greatest stress has been laid upon 
the microscopical examination and especially the microscopical diag- 
nosis. In many cases in which the clinical symptoms, although 
pointing to an affection of the genito-urinary tract, are vague, and even 
with the aid of chemical analysis of the urine will not admit of a posi- 
tive diagnosis, microscopical examination, if carefully conducted, will 
completely clear up the case. Unfortunately the majority of text- 
books on this subject still teach that diagnosis cannot be made from a 
microscopical examination of urine, except in those cases in which 
casts are present. No stress whatever is laid upon the epithelia found 
in the urine, since it is claimed that a diagnosis as to their location is 
impossible. Again, no account is taken of numerous other features 
constantly seen in pathological conditions of the genito-urinary tract, 
which are of great value in arriving at correct conclusions as to the 
condition of the patient. 

As regards the epithelia, it is undoubtedly an impossibility to 
diagnose every single epithelium found in urine, but by far the greatest 
numbers can be correctly located, and valuable deductions made there- 

vii 



viii PREFACE TO THE THIRD EDITION 

from. Low magnifying powers, such as are Irequently used for urine 
work, are decidedly useless, and a microscopical diagnosis of the differ- 
ent features seen in urine should never be attempted with a magnifying 
power of less than 400 or 500 diameters. By studying the epithelial 
formations with such powers in cases where the clinical diagnosis is 
plain, as for instance in cases of a simple cystitis or a pyelitis, it will 
soon be seen that the cellular elements are different in the different 
conditions. Again, a study of the microscopical features in cases of 
ureteritis, pyelitis, or nephritis from specimens taken by means of the 
ureteral catheter, so much resorted to at the present day, should soon 
convince even the most skeptical that a location of the majority of the 
epithelia is possible. When specimens of prostatic secretion are stud- 
ied in cases of undoubted prostatitis and spermatocystitis, and urines 
from the same cases are examined, the conclusion that many epithelia 
can be correctly located seems inevitable. 

No attention whatever is paid in text-books as to the possibility 
of diagnosing the acuteness or chronicity of a lesion, a suppurative or 
ulcerative condition, degenerations, and a number of other pathological 
changes, in all of which the features in the urine are characteristic 
enough. It is evident that a mere description of the features found 
in different cases cannot be sufficiently clear, but that illustrations 
made directly from nature are absolutely essential. The illustrations 
in this volume have been drawn by the author directly from specimens 
in his possession. The text in the present edition has been carefully 
revised and additions made where it was deemed advisable. 

In the third part, devoted to microscopical diagnosis, full-page 
illustrations have been added to elucidate the text, each drawing 
giving the different features in the case it depicts. This subject is 
undoubtedly of the greatest practical value, and a careful study of the 
different formations seen in urine cannot fail to show the importance 
of urinary diagnosis. Many mooted points in the clinical symptoms 
can often be cleared up by the microscope in a short space of time, and 
correct conclusions as to the exact condition of the patient arrived at. 
If microscopical examinations of urine are carried out more carefully 
than is generally done, even at the present time, urinalysis is bound to 
become of far greater benefit to both physician and patient than has 
so far been the case. 

Louis Heitzmann 



CONTENTS 



Introductory 
CHAPTER I 



Page 
Histology and Secretion 1 



CHAPTER II 



General Remarks 



PART FIRST 

Chemical Examination 

CHAPTER III 

General Physical and Chemical Properties (page 13) 

Normal Urine 13 

Determination of Reaction 14 

Color of Normal Urine • . . . 14 

Amount of Urine 15 

Consistency and Odor 15 

Solid Constituents of Normal Urine 16 

Urinary Pigments or Coloring Matters 17 

Gaseous Constituents 17 

Transparency and Changes upon Standing 17 

Odor and Color of Urine under Pathological Conditions 18 

Sediment of Urine under Pathological Conditions 20 

Amount of Urine under Pathological Conditions 20 

Determination of Specific Gravity 20 

Determination of Solids 22 

CHAPTER IV 

Normal Constituents (page 24) 

A. Organic (page 24) 

Total Nitrogen 24 

Urea 26 

Urease Methods. . . ' 31 

Ammonia 32 

Uric Acid 33 

Purin Bodies 36 

Creatinin 37 

ix 



x CONTENTS 

Page 

Hippurie Acid 37 

Amino Acids 37 

Oxyproteic and Alloxyproteie Acids 38 

Allantoin ... 38 

Ethereal Sulphates 38 

Coloring Matters 38 

Urochrome 39 

Haematoporphyrin 39 

Uroerythrin 39 

Urobilin 39 

Other Organic Constituents 39 

B. Inorganic (page 40) 

Chlorides 40 

Phosphates 41 

Sulphates 44 

Carbonates 45 

Centrifugal Analysis 46 

Estimation of Chlorides 46 

Estimation of Phosphates 47 

Estimation of Sulphates 47 



CHAPTER V 



Proteins (page 48 



Albuminuria 48 

Detection of Albumin in Urine 50 

1. Heat Test with Acetic Acid 50 

2. Heat Test with Nitric Acid 51 

3. Heller's Test 51 

4. Potassium-Ferrocyanide Test 52 

5. Spiegler's Test 52 

6. Sulpho-Salicylic-Acid Test 52 

7. Biuret Reaction 52 

8. Picric-Acid Test 52 

Quantitative Tests for Albumin 53 

Esbach's Albuminometer 54 

Kwilecki's Modification of Esbach's Method 54 

Tsuchiya's Method 55 

Purdy's Centrifugal Method 55 

Removal of Albumin from Urine 56 

Globulin 56 

Albumoses and Peptones 57 

Mucin (Nucleo- Albumin) 59 

Fibrin 59 

Haemoglobin 59 

Other Protein Substances 59 



CONTENTS xi 

CHAPTER VI 

Carbohydrates (.page 60) 
A. Grape Sugar (page 60) 

Page 

Grape Sugar, Dextrose,, or Glucose 60 

Detection of Sugar in Urine 61 

1. Moore-Heller Test 61 

2. Trommer's Test 61 

3. Fehling's Test 62 

4. Haines' Test 62 

5. Benedict's Test 64 

6. Bottger's Test 65 

7. Nylander's Test 65 

8. Phenylhydrazin Test 65 

Quantitative Tests for Sugar 66 

Fehling's Test 66 

Robert's Fermentation Test 66 

Einhorn's Fermentation Saccharometer 67 

Benedict's Quantitative Test ....... 67 

B. Other Carbohydrates (page 69) 

Fruit Sugar, Levulose 69 

Milk Sugar, Lactose 69 

Maltose or Isomaltose 69 

Cane Sugar, Saccharose 70 

Pentoses 70 

Glycuronic Acid 70 

Cammidge's Reaction 70 



CHAPTER VII 

Other Abnormal Constituents (page 72) 

Acetone Bodies 72 

Acetone 74 

Diacetic Acid 75 

/3-Oxybutyric Acid 76 

Indican 77 

Skatoxyl Potassium Sulphate 78 

Ehrlich's Diazo Reaction 78 

Coloring Matters 79 

Bile Pigments 79 

Coloring Matter of Blood 80 

Haematoporphyrin , 81 

Melanin 81 

Alkapton 82 

Fatty Matters 82 

Leucin and Tyrosin 82 

Cystin 82 



xii CONTENTS 

PART SECOND 

Microscopical Examination 

CHAPTER VIII 

General Considerations (page 85) 

Page 

Use of Centrifuge > 86 

Mounting of Sediment 88 

Use of Antiseptic Substances 88 

Preservation of Sediment 88 

Use of Microscope and Magnifying Powers 89 

CHAPTER IX 

Crystalline and Amorphous Sediments (page 93) 

I. Acids and Salts (page 93) 

A. Acid Sediments 93 

1. Uric Acid 93 

2. Sodium Urate 99 

3. Calcium Oxalate 100 

4. Cystin : 103 

5. Creatinin. . 103 

6. Hippuric Acid 105 

7, 8. Leucin and Tyrosin 106 

9. Calcium Sulphate 107 

B. Alkaline Sediments 107 

1. Triple Phosphates 107 

2. Simple Phosphates 110 

3. Ammonium Urate 112 

4. Calcium Carbonate 114 

5. Magnesium Phosphate 115 

II. Other Unorganized Sediments (page 115) 

Fat 115 

Cholesterin 116 

Haematoidin 117 

Indigo 118 

Melanin 119 

Urinary Concretions (page 119) 

CHAPTER X 

Blood-Corpuscles and Pus-Corpuscles (page 121) 
I. Blood-Corpuscles (page 121) 

Red Blood-Corpuscles or Red Blood-Cells 121 

White Blood-Corpuscles or Leucocytes 122 

Fibrin 122 

Blood-Clots 123 

Source of Blood-Corpuscles 123 



CONTENTS xiii 
II. Pus-Corpuscles (page 125) 

Page 

Pyuria 126 

Changes in Pus-Corpuscles 127 

Source of Pus-Corpuscles 128 

Tests for Pus 129 



CHAPTER XI 
Epithelia (page 131) 

Epithelia Common to Both Sexes 133 

Epithelia from the Bladder 133 

Epithelia from Pelvis of Kidney 135 

Epithelia from the Ureters 136 

Epithelia from the Uriniferous Tubules of Kidneys 136 

Epithelia Found in Urine of Male 139 

Epithelia from Urethra 139 

Ephithelia from Prostate Gland 139 

Epithelia from Seminal Vesicles 141 

Epithelia from Ejaculatory Ducts 141 

Sperma 142 

Urethral and Gleet-Threads 142 

Epithelia Found in Urine of Female 145 

Epithelia from Vagina . 145 

Smegma . 145 

Epithelia from Bartholinian Gland 146 

Epithelia from Cervix Uteri 146 

Epithelia from Mucosa Uteri 147 



CHAPTER XII 

Mucus and Connective Tissue (page 149) 
I. Mucus (page 149) 

Mucus- Threads and Corpuscles 150 

Mucus-Casts or Cylindroids 151 

II. Connective Tissue (page 151) 

1. Ulceration 153 

2. Suppuration 153 

3. Hemorrhage 154 

4* Traumatism 154 

5. Tumors 155 

6. Hypertrophy of Prostate Gland 156 

7. Stricture of Urethra 156 

8, 9. Cirrhosis and Atrophy of Kidney 157 

10. Intense Inflammations 157 



xiv CONTENTS 

CHAPTER XIII 

Tubular Casts (page 158) 
I. True Casts (page 159) 

Page 

1. Hyaline Casts. 160 

2. Epithelial Casts 162 

3. Blood-Casts 163 

4. Granular Casts 163 

5. Fatty Casts 166 

6. Waxy Casts 167 

7. Mixed Casts 169 

Other Casts 169 

II. False or Pseudo Casts (page 170) 

Urate Casts 170 

Bacterial Casts 172 

Pus-Casts 172 

Fat-Casts 172 

Fibrin-Casts. 172 

CHAPTER XIV 

Micro-organisms and Animal Parasites (page 173) 
I. Micro-organisms, or Fungi (page 173) 

Non-pathogenic Micro-organisms 173 

1. Mould Fungi 173 

2. Yeast Fungi 174 

3. Fission Fungi 176 

Pathogenic Schizomycetes . ' 177 

Gonococci 178 

Other Cocci 181 

Tubercle Bacilli 181 

Typhoid Bacilli 185 

Bacillus Coli Communis 186 

Actinomyces 186 

II. Animal Parasites, or Entozoa (page 187) 

Trichomonas Vaginalis 187 

Echinococci 188 

Distoma Haematobium 189 

Filaria Sanguinis Hominis 190 

Ascaris Lumbricoides 191 

Other Parasites 192 

CHAPTER XV 
Extraneous Matters (page 193) 

Cotton Fibres 193 

Linen Fibres 194 

Silk Fibres 194 



CONTENTS xv 

Page 

Wool Fibres 194 

Human Hairs . . 194 

Feather 195 

Scales from Moth 196 

Starch-Globules , 197 

Lycopodium 197 

Cellulose 198 

Cork 200 

Oil-Globules and Air-Bubbles 200 

Haws in Glass 200 

Vegetable Matter 202 

Faeces 203 



PART THREE 

Microscopical Urinary Diagnosis 

Introductory 207 

CHAPTER XVI 

Diseases of the Kidney and Pelvis of Kidney (page 209) 
I. Inflammations of the Kidney and Its Pelvis (page 209) 

Classification 209 

Pathological Changes 212 

1. Interstitial Inflammation 212 

2. Parenchymatous Inflammation 213 

3. Suppurative Inflammation 214 

Congestion or Hyperemia of the Kidney .215 

Causes 215 

Interstitial or Catarrhal Nephritis .216 

Causes 216 

Clinical Symptoms 217 

Features Found in Urine 217 

Acute Interstitial or Catarrhal Nephritis . 221 

Chronic Interstitial or Catarrhal Nephritis 221 

Subacute Interstitial Nephritis 222 

Cirrhosis of the Kidney 225 

Catarrhal Pyelitis 225 

Ureteritis 226 

Parenchymatous or Croupous Nephritis 226 

Causes 226 

Clinical Symptoms 229 

Features Found in Urine 229 

Acute Parenchymatous or Croupous Nephritis 230 

Subacute Parenchymatous Nephritis 234 

Chronic Parenchymatous Nephritis 234 

Atrophy of the Kidney 240 



xvi CONTENTS 

Page 

Chronic Parenchymatous Nephritis with Acute Parenchymatous 

Exacerbation 245 

Suppurative Nephritis 246 

Causes 246 

Clinical Symptoms 249 

Features Found in Urine 249 

Suppurative Pyelitis 250 

Tuberculosis of the Kidney 253 

Features Found in Urine 253 

II. Anomalies of Secretion (page 257) 

Causes • 257 

Clinical Symptoms 257 

Lithoemia 257 

Hemorrhage from the Pelvis of the Kidney 258 

Pyelitis Calculosa 261 

Oxaluria 261 

Hcemoglobinuria 262 

Causes 262 

Features Found in Urine 262 

Chyluria . . 267 

Features Found in Urine 268 

III. Malignant Tumors of the Kidney (page 271) 

Clinical Symptoms 271 

Appearance of Urine 271 

Sarcoma 271 

Features Found in Urine 272 

Cancer 275 

CHAPTER XVII 

Diseases of the Bladder (page 276) 

I. Inflammations of the Bladder (page 276) 

Causes 276 

Clinical Symptoms 277 

Appearance of Urine 278 

Catarrhal Cystitis 278 

Microscopical Features 278 

Acute Catarrhal Cystitis 278 

Chronic Catarrhal Cystitis 282 

Subacute Catarrhal Cystitis 285 

Ulcerative Cystitis 285 

Acute Ulcerative Cystitis 285 

Chronic Ulcerative Cystitis 286 

Suppurative Cystitis 286 

Pericystitis 291 

II. Tumors of the Bladder (page 292) 

Clinical Symptoms 292 

Papilloma 292 

Microscopical Features 292 



CONTENTS xvii 

Page 

Sarcoma 296 

Microscopical Features 296 

Carcinoma 296 

Microscopical Features 299 

III. Parasites in the Bladder (page 300) 

CHAPTER XVIII 

Diseases of the Sexual Organs (page 303) 

Urethritis 303 

Acute Urethritis 303 

Chronic Urethritis 303 

Prostatitis 304 

Causes 304 

Clinical Symptoms . . 304 

Features Found in Urine 305 

Acute Prostatitis 305 

Chronic Prostatitis 306 

Hypertrophy of the Prostate Gland 311 

Tuberculosis of the Prostate Gland 311 

Tumors 312 

Spermatorrhoea 312 

Seminal Vesiculitis 315 

Clinical Symptoms 315 

Features Found in Urine 315 

Hemorrhage from the Seminal Vesicles 316 

Vaginitis 321 

Features Found in Urine 321 

Catarrhal Vaginitis 321 

Ulcerative Vaginitis 322 

Traumatic Vaginitis . . . : 322 

Cervicitis and Endometritis 327 

CHAPTER XIX 

Determination of the Functional Efficiency of the Kidneys (page 329) 

Phenolsulphonephthalein Test 332 

Indigo- Carmine Test 334 

Phloridzin Test 336 

Methylene Blue Test 337 

Cryoscopy 338 

Experimental Polyuria 339 

Electric Conductivity of the Urine 340 

Toxicity Test 340 

Appendix (page 341) 

Report on Examination of Urine 341 

Lists of Apparatus and Reagents Required for Urinary Analysis 343 

Apparatus 343 

Liquid Reagents 344 

Staining Reagents for Bacteria 346 

Solid Reagents 346 



LIST OF ILLUSTRATIONS 



Fig. Page 

1. Malpighian Corpuscle 2 

2. Diagram of the Kidney 3 

3. Cortical Substance of the Kidney. Transverse Section. Blood- Vessels 

Injected 4 

4. Medullary Substance of the Kidney. Transverse Section. Blood- 

vessels Injected 4 

5. Injected Blood- Vessels of the Cortical Substance of the Kidney of a Dog. 5 

6. Urinometer 21 

7. Saxe's Urinopykno meter 22 

8. Crystals of Urea and Nitrate of Urea 27 

9. Doremus' Ureometer 29 

10. Hinds' Modification of Doremus' Ureometer 30 

11. Ruhemann's Uricometer 35 

12. Horismascope . . 53 

13. Esbach's Albuminometer 53 

14. Einhorn's Fermentation Saccharometer 67 

15. Sedimentation Glass 85 

15a. Spaeth's Sedimentation Glass 85 

16. Hand Centrifuge : 86 

17. Water-power Centrifuge 86 

18. Sedimentation Tubes for Centrifuge 87 

19. Crystals of Uric Acid, Common Form 94 

20. Crystals of Uric Acid, Common Form 95 

21. Crystals of Uric Acid, from Highly Acid Urine 96 

22. Uric- Acid Concretions 97 

23. Pale Uric-Acid Crystals 98 

24. Sodium Urate, Amorphous 99 

25. Sodium Urate, Crystalline 100 

26. Granules of Sodium Urate Changing to Globules and Dumb-Bells . . . 101 

27. Calcium Oxalate Crystals 102 

28. Cystin Crystals 103 

29. Creatinin Crystals 104 

30. Sediment in the Urine of an Athlete 104 

31. Hippuric Acid 105 

32. Leucin and Tyrosin 106 

33. Calcium Sulphate Crystals 107 

34. Complete Triple Phosphates 108 

35. Incomplete Triple Phosphates 109 

36. Amorphous Simple Phosphates : 110 

37. Star-shaped Simple Phosphates Ill 

38. Ammonium Urate 112 

39. Acid Sediment in Fermentation and in Transition to Alkaline 113 

40. Calcium Carbonate and Magnesium Phosphate 114 

41. Fat-Globules and Margaric- Acid Needles 115 

xix 



xx LIST OF ILLUSTRATIONS 

Fig. Page 

42. Cholesterin Crystals 117 

43. Haematoidin Crystals : 117 

44. Indigo Crystals 118 

45. Blood-Corpuscles 122 

46. Fibrin and Blood-Clot 123 

47. Pus-Corpuscles 126 

48. Pus-Corpuscles Showing Various Changes 127 

49. Epidermal Scales . 133 

50. Epithelia from the Bladder 134 

51. Epithelia from Pelvis of Kidney and Ureter 136 

52. Epithelia from Uriniferous Tubules of Kidneys 137 

53. Comparative Sizes of Corpuscles and Epithelia 138 

54. Epithelia from Urethra 139 

55. Epithelia from Prostate Gland, Seminal Vesicles, and Ejaculatory Ducts. 140 

56. Sperma as Found in Urine 141 

57. Gleet-Threads 143 

58. Epithelia from the Vagina 144 

59. Smegma from the Clitoris 146 

60. Epithelia from Bartholinian Gland, Cervix Uteri, and Mucosa Uteri . . 147 

61. Mucus-Threads and -Corpuscles 150 

62. Mucus-Casts or Cylindroids 151 

63. Connective-Tissue Shreds. . 152 

64. Connective-Tissue Shreds Found in Tumors 155 

65. Hyaline Casts 161 

66. Epithelial Casts 162 

67. Blood Casts 164 

68. Granular Casts 165 

69. Fatty Casts 166 

70. Waxy Casts 167 

71. Mixed Casts 168 

72. Casts of Ammonium Urate and Sodium Urate 170 

73. False or Pseudo Casts 171 

74. OidiumLactis 174 

75. Penicillium Glaucum and Aspergilli 175 

76. Saccharomycetes 176 

77. Schizomycetes 177 

78. Acute Gonorrhoea 179 

79. Chronic Gonorrhoea 180 

80. Tuberculosis of the Kidney 184 

81. Bacillus Coli Communis 185 

82. Actinomyces 186 

83. Trichomonas Vaginalis 187 

84. Portions of Echinococcus . . . 188 

85. Ova of Distoma Haematobium 189 

86. Filaria Sanguinis Hominis 190 

87. Ova and Portion of Ascaris Lumbricoides 191 

88. Cotton Fibres 193 

89. Linen Fibres 194 

90. Silk Fibres 195 

91. Wool Fibres 195 



LIST OF ILLUSTRATIONS xxi 

Fig. Page 

92. Feather 196 

93. Scales from Wings of Moth 196 

94. Starch Globules 197 

95. Lycopodium Globules 198 

96. Cellulose 198 

97. Cork 199 

98. Oil-Globules and Air-Bubbles 199 

99. Flaws in the Glass 200 

100. Vegetable Matter 201 

101. Normal Faeces 202 

102. Acute Interstitial Nephritis (Acute Catarrhal Pyelo-nephritis) and 

Cystitis 219 

103. Chronic Interstitial Nephritis (Chronic Catarrhal Pyelo-nephritis) and 

Cystitis 223 

104. Cirrhosis of the Kidney, with Chronic Catarrhal Cystitis 227 

105. Acute Parenchymatous or Croupous Nephritis, with Pyelitis and 

Catarrhal Cystitis 231 

106. Acute Hemorrhagic Parenchymatous or Croupous Nephritis, with 

Pyelitis and Catarrhal Cystitis 235 

107. Subacute Parenchymatous or Croupous Nephritis, with Pyelitis and 

Catarrhal Cystitis 237 

108. Chronic Parenchymatous or Croupous Nephritis, with Fatty Degenera- 

tion of the Kidney, Accompanying Pyelitis and Catarrhal Cystitis. 241 

109. Chronic Parenchymatous or Croupous Nephritis, with Fatty and Waxy 

Degeneration of the Kidney, Accompanying Pyelitis 243 

110. Chronic Parenchymatous or Croupous Nephritis, with Fatty and Waxy 

Degeneration of the Kidney and an Acute Hemorrhagic Croupous 

Exacerbation, Pyelitis, and Catarrhal Cystitis 247 

111. Chronic Suppurative Nephritis, with Catarrhal Pyelitis 251 

112. Acute Abscess of Pelvis of Kidney, or Acute Suppurative Pyelitis . . . 255 

113. Lithsemia, with Subacute Pyelitis and Catarrhal Cystitis 259 

114. Hemorrhage from Pelvis of Kidney, Due to Uric- Acid Calculus .... 263 

115. Hemoglobinuria, Acute Hemorrhagic Croupous or Parenchymatous 

Nephritis, with Catarrhal Pyelitis 265 

116. Chyluria, Catarrhal Cystitis 269 

117. Sarcoma of Kidney, Chronic Pyelitis and Catarrhal Cystitis 273 

118. Acute Catarrhal Cystitis 279 

119. Chronic Catarrhal Cystitis 283 

120. Acute Ulcerative Cystitis 287 

121. Chronic Ulcerative Cystitis 289 

122. Pericystitis, Due to Parametritis 293 

123. Hemorrhage from the Bladder, Due to Papilloma of Bladder 297 

124. Villous Cancer of the Bladder 301 

125. Acute Abscess of the Prostate Gland 307 

126. Chronic Prostatitis 309 

127. Chronic Prostatitis, with Hypertrophy of the Prostate Gland 313 

128. Chronic Spermatocystitis, or Seminal Vesiculitis 317 

129. Hemorrhage from Seminal Vesicles, with Acute Prostatitis 319 

130. Chronic Catarrhal Vaginitis 323 

131. Ulcerative Vaginitis : 325 



URINARY ANALYSIS AND DIAGNOSIS. 



INTRODUCTORY. 

CHAPTER I. 

HISTOLOGY AND SECRETION. 

The kidney is a compound tubular gland, which consists of an outer, 
cortical, and an inner, medullary or pyramidal, substance; its surface is 
ensheathed by a dense, fibrous connective-tissue capsule. The main 
constituents of the kidney are the blood-vessels and the uriniferous tu- 
bules; these are held together by a delicate, fibrous connective tissue. 
In the cortical substance, which contains the Malpighian corpuscles, the 
tubules are convoluted, while in the medullary substance they run a 
more nearly straight course. 

Each Malpighian corpuscle is composed of a delicate connective-tissue 
capsule — the capsule of Bowman — and the glomerulus or tuft consisting 
of a number of convolutions of capillary blood-vessels (see Fig. 1). Both 
the inner or glomerular and the outer free surface of Bowman's capsule 
are lined by flat epithelium in the adult. Between the capsule and the 
glomerulus there is a space, the size of which differs according to the state 
of secretion. The glomerulus is connected with an afferent and an effer- 
ent arterial blood-vessel, the former being the larger of the two, while 
opposite the site of the blood-vessels the uriniferous tubules originate. 

The uriniferous tubules are divided into a number of different seg- 
ments, which are the following: 1. Proximal convoluted tubule. 2. 
Narrow tubule. 3. Distal convoluted tubule. 4. Arched or straight 
collecting tubule. From a confluence of a number of collecting tubules 
the larger collecting tubules are formed, which in turn unite to form the 
papillary ducts or tubules of Bellini ; these pass through the renal papillae 
and empty into the calyces and pelvis of the kidney. The course of 
the uniferous tubules as well as of the blood-vessels is represented in 
Fig. 2, a diagram of the kidney. 

1 



2 URINARY ANALYSIS AND DIAGNOSIS. 

The proximal convoluted tubule originates from the capsule of Bow- 
man as a slightly narrowed, funnel-shaped neck, and, after repeated 
convolutions in the cortex, tends downward into the medulla. Here it 
becomes narrow and represents the descending branch of Henle's loop. 
After reaching certain depths in the medullary substance, it turns upon 
itself, producing Henle's loop, and passes again toward the surface as 
the ascending branch of the narrow tubule or of Henle's loop. It now 
widens, and, at the most peripheral part of the cortex in which there are 




ct 



Fig. 1. — Malpighian Corpuscle. 
T, Capillary loops of the glomerulus, in connection with the afferent artery, covered by 
E, flat epithelia; Ca, capsule covered with flat epithelia, in communication with Co, the 
convoluted tubule; CL, convoluted tubule in longitudinal section; CT, convoluted tubule 
in transverse section (X 350). 



no glomeruli, again becomes a convoluted tubule — the distal convoluted 
tubule, also known as the intercalated tubule, which inosculates with 
the arched or straight collecting tubule. The latter runs down through 
the medulla, unites with other arched tubules, becomes broader, and 
enters the papilla as tubule of Bellini, which empties into the calyx and 
pelvis of the kidney. 

The uriniferous tubules are lined by a single layer of epithelia, and 
each portion has its peculiar epithelial lining. In a general way, this is 
cuboidal in the convoluted tubules, flat in the narrow, and columnar in 
the collecting tubules, although different portions of both the narrow and 
collecting tubules are also lined by cuboidal epithelia. All tubules are 



HISTOLOGY AXV SECRETION. 




Diagram of the Kidney. 



T, Malpighian corpuscle; CT, capsule of Malpighian corpuscle; CI, proximal con- 
voluted tubule ; .V, narrow or looped tubule ; CH, distal convoluted tubule ; S, straight 
collecting tubule in the medullary ray of the cortical substance; C, straight collecting 
tubule in the medullary substance; P, straight collecting tubule in the papilla; A, renaj 
artery; V, renal vein; AV, afferent vessel; EV, efferent vessel; B, arterial branch to the 
cortical substance; AP, arterial branch to the medullary substance; CC, capillaries of 
convoluted tubules; CS, capillaries of narrow tubules; CP, capillaries of straight collect- 
ing tubules; VR, blood-vessels of the medullary substance; L, capillaries of papilla. 
The sum total of the convoluted tubules is termed the labyrinth, while the straight 
tubules, both narrow and collecting, produce the medullary rays between the labyrinths 
in the cortex. 



4 URINARY ANALYSIS AND DIAGNOSIS. 

surrounded by a delicate connective tissue which carries the blood-ves- 
sels and nerves. 

The peculiarities of the cortical and medullary substances are shown 
in Figs. 3 and 4. 




Fig. 3. — Cortical, Substance of the Kidney. Transverse Section. Blood- 
vessels Injected (X 500). 
C, Convoluted tubule; N, narrow tubule; NA, ascending branch of narrow tubule; 
.S, straight collecting tubule. 




ND 



Fig. 4. — Medullary Substance of the Kidney. Transverse Section. Blood- 
vessels Injected ( X 500). 
N, Narrow tubule ; ND, descending branch of narrow tubule ; S, straight collecting 



HISTOLOGY AND SECRETION. 5 

The vascular supply of the kidney is in intimate relation with the 
uriniferous tubules. The renal artery divides into a number of branches,, 
known as the interlobar arteries, which, upon reaching the boundary 
zone between the cortical and medullary substance, bend sharply and 
produce the arterial arches. Each artery is accompanied by a vein, the 




Fig. 5. — Injected Blood-Vessels of the Cortical Substance of the Kidney of a 

Dog (X 100). 
Ca, Capsule; O, outer zone, devoid of Malpighian corpuscles; T, Malpighian cor- 
puscle; A, afferent vessel; E, efferent vessel; R, branch of renal artery; Co, zone of 
convoluted tubules; S, zone of straight tubules. 



veins being connected by lateral branches and producing a venous plexus. 
From the arches straight arterial branches — the interlobular arteries — 
arise, which penetrate the cortical substance, divide, and give off numer- 
ous transverse twigs — the afferent vessels of the glomerulus (see Fig. 5). 



6 URINARY ANALYSIS AND DIAGNOSIS. 

The afferent vessel breaks up into a number of small branches which in 
turn give rise to groups of capillaries forming the glomerulus. Larger 
capillaries, arising from the smaller, unite to form the efferent vessel, 
which leaves the glomerulus near the entrance of the afferent vessel, and 
is smaller than the latter. The entire blood supply of the glomerulus is 
arterial. The efferent vessel soon divides freely into capillaries, for the 
supply of the cortical as well as the medullary substance. In these capil- 
laries the blood gradually becomes venous and passes into the interlobu- 
lar veins, which accompany the arteries to the boundary between the 
cortical and the medullary substance; here they enter the venous arches 
which accompany the arterial arches. 

The kidney is richly supplied with medullated and non-medullated 
nerve fibres, which accompany the arteries and may be traced to the 
epithelia of the uriniferous tubules. 

Urine, the excretion from the kidneys, is produced partly by the 
process of filtration in the glomeruli, and partly by the activity of the 
epithelia of the uriniferous tubules. In the glomeruli, not only the 
water is derived from the blood, but also certain inorganic salts, such as 
sodium chloride, and possibly a few other solids are separated. The 
amount of the fluid filtered off depends almost entirely upon the blood 
pressure in the glomeruli. The epithelia of the uriniferous tubules con- 
stitute the true secretory structure of the kidney. 

These views, which were first promulgated by Bowman in the year 
1842, were later corroborated by experiments of Heidenhain, who injected 
indigo- carmine into the blood of animals, and found that a blue color 
appeared in the urine soon afterward, and that the epithelia of the con- 
voluted and ascending branch of the narrow tubules were stained blue, 
while the Malpighian corpuscles did not show the slightest traces of the 
stain. After section of the spinal cord, which causes lowering of the 
blood pressure in the renal glomeruli, and injection of indigo-carmine 
the epithelia of the uriniferous tubules were stained blue with this sub- 
stance, which was also found in the lumen of the tubules, while the glo- 
meruli were free from stain. This appears to show that under ordinary 
circumstances the indigo-carmine is eliminated by the tubular epithelia, 
and that, when by diminishing the blood pressure the filtration of urine 
ceases, the substance remains in the tubules. 

In the light of our present knowledge upon this subject, it is evident 
that most of the saline constituents of the urine are the excretory prod- 
ucts of those uriniferous tubules which are richly supplied with capillary 
blood-vessels and the epithelia of which are closely connected with the 
walls of the vessels. The thickened blood contained in these vessels re- 



HISTOLOGY AND SECRETION. 7 

absorbs a portion of the liquid from the tubules and supplies the liquid 
in the tubules with a certain amount of its salts. The whole process is 
accomplished through the agency of the living epithelia, and is not to be 
considered a simple process of osmosis. The differences in the struct- 
ure of the epithelia in certain portions of the uriniferous tubules, and 
the striking differences in the distribution of the blood-vessels, strongly 
point toward a difference in the function of portions of the tubules, even 
though up to the present time no exact demonstration of these functions 
concerning the constituent elements of the urine has been furnished. 

Pathological conditions also prove that the renal epithelia possess im- 
portant functions. In diseases in which the function of the tubules is 
much interfered with, their epithelial lining being destroyed to a consid- 
erable degree, urea and allied products are retained in the system, and 
the phenomena of uraemia result. The urine in such cases is of a more 
watery character than normally, has a lower specific gravity, and con- 
tains a smaller amount of its characteristic solids. 



CHAPTER II. 

GENERAL REMARKS. 

Urinary analysis, in order to be thorough arid of practical value, 
must necessarily be both chemical and microscopical. Chemical exam- 
ination, although of great importance, can alone never lead to a correct 
diagnosis ; only through the use of the microscope the nature of the dis- 
ease in the genito-urinary tract, as well as its exact location, can be re- 
vealed. Every urine to be examined should be first subjected to different 
chemical tests, the extent of which will vary with the different cases, and 
then to a microscopical examination. 

In the majority of cases the simpler chemical tests alone will be re- 
quired. These must be made, first, with a view of determining the char- 
acter and amounts of the normal constituents of the urine ; secondly, for 
the purpose of learning of the presence of any abnormal constituent. A 
general knowledge of the normal constituents is, therefore, necessary; 
and we must not lose sight of the fact that these may vary to a consider- 
able degree, even in perfect health, partly from diet, and partly from 
conditions of rest or activity. An increased or diminished amount of 
any ingredient does not necessarily mean a pathological condition, al- 
though when this increase or diminution lasts for a long time a diseased 
condition becomes certain. 

In selecting a specimen for examination, it is essential for accurate 
diagnosis to obtain the total amount of urine passed during the whole 
twenty-four hours, or to have the patient collect the entire amount, 
measure it carefully, note the exact quantity, and send from four to eight 
ounces of the mixed urine. In collecting the twenty-four hours' amount, 
mistakes are frequently made. The procedure should be the following: 
A certain time — for instance, eight o'clock in the morning — is selected 
for starting the collection of urine; the bladder should be emptied at this 
time and the urine voided thrown away; every drop of urine subse- 
quently voided is carefully collected, the patient being instructed to void 
and collect the urine before each movement of the bowels, the last amount 
taken being at eight o'clock the following morning. The amount of 
urine is now measured and noted. The urine may be kept in clean bot- 
tles of any size, although a bottle holding about half a gallon is preferable. 

The reasons for collecting the twenty-four hours' amount are various; 

8 



GENERAL REMARKS. 9 

not only is the total quantity voided important in diagnosing different 
affections, but the proportions of the normal as well as of the pathological 
ingredients vary considerably at different hours of the day and night, so 
that the exact amounts of these ingredients cannot be determined when 
specimens from single urinations are examined. In cases in which the 
quantitative estimation of urea and solids generally is not essential, or in 
which the total twenty-four hours' amount cannot be obtained, it is best 
to obtain the specimen during the day, a few hours after meals, or in the 
evening. The urine first voided in the morning, although usually the 
most concentrated, is not the best for examination, since different patho- 
logical ingredients, such as albumin and even sugar, may be absent in the 
morning and yet be present in varying amounts at other times. If any 
doubt remains as to the exact condition in such cases, two samples, 
passed at different times, must be tested. 

Care should be taken that the bottles in which the urine is kept are 
scrupulously clean and well corked, and that the urine be obtained in as 
fresh a condition as possible. When the whole twenty-four hours' urine 
is collected, the bottle should be kept in a cool place and the urine poured 
into it as soon as possible after being voided. Even then, secondary 
changes cannot always be guarded against. In cold weather such changes 
will usually not take place for many hours, but in warm weather decom- 
position is apt to set in at the end of a few hours, and bacteria develop 
in varying numbers. When not absolutely necessary, it is not advisable 
to add any preservatives to the urine until after the chemical tests have 
been made. Extraneous objects can easily find their way into the urine 
when care is not exercised as to cleanliness, and these not infrequently 
lead to confusion in examination. 

When urine is received for examination, it should be set aside for at 
least six hours, that a sediment may be deposited, unless it is preferred 
to use the centrifuge, when examination can proceed at once. In the 
former case the upper part of the urine is used for chemical tests, and the 
sediment for microscopical examination; while in the latter a small 
amount is used for the centrifugal apparatus, and chemical examination 
can at once be conducted with the remainder. 

After determining the amount of urine voided in twenty-four hours, 
we must note the color, odor, transparency, and reaction, and carefully 
determine the specific gravity. The approximate amount of urea voided 
in twenty-four hours should then be estimated by chemical tests, and 
the total amount of solids voided, determined. As urea, the chief organic 
constituent of urine, forms approximately forty to fifty per cent of all 
the solid ingredients, the specific gravity of the specimen will frequently 
give an idea of its increase or diminution in a given case. That errors 



10 URINARY ANALYSIS AND DIAGNOSIS. 

are liable to result from such an estimation is evident, and wherever pos- 
sible a ureometer should be used. 

The next step should always be the determination of the presence or 
absence of albumin, as well as its approximate amount if present, while 
further chemical tests will vary with each individual case. Whenever 
the specific gravity is above normal, or any clinical symptoms lead to a 
suspicion of the presence of sugar, even at a low specific gravity, tests 
for sugar must be resorted to. Should it be desired to know the approx- 
imate amounts of uric acid, chlorides, sulphates, and phosphates present, 
though this is not always essential for the diagnosis, the simpler tests for 
these ingredients will, as a rule, be all that are required. 

Before resorting to microscopical examination, the nature of the sedi- 
ment, whether it is present in small or large amount, its color, and its 
general character should be noted; and then all the elements found un- 
der the microscope, as well as their comparative numbers, should be 
carefully observed. It will always be safest to examine a number of 
drops before coming to a conclusion and determining upon the diagnosis. 



PART FIRST. 

CHEMICAL EXAMINATION. 



PART FIRST. 

CHEMICAL EXAMINATION. 



CHAPTER III. 

GENERAL PHYSICAL AND CHEMICAL PROPERTIES. 

Normal urine is a yellowish, transparent liquid, of a peculiar odor, 
and always of an acid or faintly acid reaction, when the entire twenty- 
four hours' amount from a person on a mixed diet is tested. This 
reaction was until recently supposed to be due to the presence of acid 
salts, especially to acid sodium phosphate (monosodium phosphate 
or sodium dihydrogen phosphate of the formula NaH 2 P0 4 ), which 
turns blue litmus paper red, and not to the presence of any free acid. 
The degree of acidity was believed to depend upon the amount of the 
acid sodium phosphate as compared with that of the alkaline disodium 
phosphate (of the formula Na 2 HP0 4 ). Urine is rarely neutral, but it 
occasionally gives both reactions with litmus paper — that is, turns 
blue litmus red and red litmus blue. This reaction is known as 
amphoteric and was supposed to be due to the presence in variable 
proportions of both acid monosodium and alkaline disodium phosphate. 

Recent researches by Folin and others tend to overthrow this 
theory, and the acidity is now considered to be due to the presence of 
phosphoric acid, sulphuric acid, and various free organic acids. The 
different acids which take part in the acid reaction of a urine affect 
the reaction in proportion to their dissociation, since in accordance with 
what is known as the " ionic theory," the acid reaction of a solution 
depends upon the amount of hydrogen ions present. 

The degree of acidity of the urine varies at different times of the 
day, and is considerably influenced by the food. The acidity is, as a 
rule, highest in the morning before breakfast, and is diminished 
after a meal on account of the secretion of hydrochloric acid into the 

13 



14 URINARY ANALYSIS AND DIAGNOSIS. 

stomach. It reaches its lowest point a few hours after a meal, when it 
may even be temporarily alkaline, and the urine may be turbid from 
the precipitation of phosphates. This temporary change in the reac- 
tion has been called the " alkaline tide" of the urine. An exclusive 
protein diet causes an increase of acidity, and such an increase is 
also seen after excessive muscular exercise and after hot baths with free 
perspiration. After ingestion of large amounts of vegetables and alka- 
line waters, there is a diminution of acidity, and the reaction may 
even temporarily become alkaline. 

Determination of Reaction. — For all clinical purposes the determina- 
tion of the reaction by means of litmus paper is sufficient; blue litmus 
paper turning red in acid urine, and red litmus paper turning blue 
in alkaline urine. A rough idea of the degree of acidity or alkalinity 
can be obtained by the intensity of the change in color, and may be 
noted as "faintly acid or alkaline," "moderately acid or alkaline," 
and "highly acid or alkaline." When it gives both reactions with 
litmus paper, as is not rarely the case, the reaction is known as 
"amphoteric." 

For the determination of the total acidity of the urine the most 
reliable method is that of Folin: Place 25 c.c. of urine into a 200 c.c. 
Erlenmeyer flask, add one or two drops of a five-tenths or one per cent 
alcoholic solution of phenolphthalein, and 15 to 20 grams of finely 
powdered potassium oxalate. Shake the mixture thoroughly for one 
to two minutes and titrate it immediately with a decinormal sodium 
hydroxide solution, the shaking being continued. The sodium hy- 
droxide is added until a faint but distinct pink color appears and re- 
mains permanent ; this is the end point. The percentage of total acidity 
is expressed in terms of the numbers of cubic centimetres of deci- 
normal sodium hydroxide used to neutralize the acidity of the total 
amount of urine passed in twenty-four hours. The acidity may 
also be expressed as grams of hydrochloric acid, 1 c.c. of a deci- 
normal sodium hydroxide solution being equivalent to 0.00365 grams 
of hydrochloric acid. To calculate the acidity of the urine in terms 
of hydrochloric acid, multiply the numbers of cubic centimetres of 
decinormal sodium hydroxide required by the twenty-four hour urine 
by 0.00365. Normally the acidity of the twenty-four hour urine 
corresponds to between 1.15 and 2.3 grams of hydrochloric acid. 

The color of normal urine is yellowish or amber, although the tints 
even in health may vary considerably and generally depend upon the 
degree of concentration and the pigments. The reaction also has an in- 
fluence upon the color, and highly acid urine frequently becomes darker 
upon standing, due to the oxidation of chromogens. 



PHYSICAL AND CHEMICAL PROPERTIES. 15 

According to Vogel, the following color tints may be distinguished: 

1 . Pale yellow 

2. Light yellow \ Yellow urines 

3. Yellow I 

4. Reddish-yellow ] 

5. Yellowish-red \ Reddish urines 



6. Red 

7. Brownish-red 

8. Reddish-brown Brown or dark urines 

9. Brownish-black J 

Pale or light yellow urines are rarely highly acid, but usually faintly 
acid, amphoteric, or alkaline, and denote dilution and an increase in the 
amount of urine. Reddish-yellow to brownish-red urines are usually 
rich in solid constituents, contain considerable urea, and are not highly 
acid. Abnormally dark urines may be due to accidental pigments or 
medicines. A dark yellow or reddish-yellow color may be due to rhu- 
barb, senna, santonin, or considerable salicylic acid; a red color, to 
antipyrin, antifebrin, sulfonal, or trional; a brownish-black color, to 
resorcin, tannin, carbolic acid, guaiacol, or thymol; a greenish-black 
color, to salol or pyrogallol; and a blue or greenish-blue color, to 
methylene blue. 

The average amount of urine passed by a healthy adult in twenty-four 
hours is about 1,500 cubic centimetres, or 50 ounces, although it varies 
between 1,200 and 1,800 c.c, women passing somewhat smaller quanti- 
ties than men. The specific gravity varies from 1.015 to 1.025, the 
average being 1.020. 

The amount of urine voided is greatly influenced by different 
factors. It is greater the more liquid is taken into the body, and as the 
amount of solids, which determines the specific gravity, usually remains 
about the same in health, it follows that the specific gravity will be 
lower the greater the quantity voided. The amount of the perspira- 
tory excretion has a great bearing upon the quantity of the urine, and 
in cold weather, when the perspiration is lessened, the urine increases 
in amount. Different articles of diet, such as tea and coffee, un- 
doubtedly stimulate the excretion of urine. Nervous excitement, 
anxiety, and hard mental work have the same effect. Bodily exer- 
cise, increasing perspiration, lessens the amount of urine, and there- 
fore renders it more concentrated. The specific gravity of urine voided 
at different hours of the day may, therefore, vary to a great degree, 
sometimes being as low as 1.002 or 1.003, and at other times 1.030, 
without indicating, in any manner, a pathological condition. 

Consistency and Odor. — Normal urine is of a watery consistency and 



16 URINARY ANALYSIS AND DIAGNOSIS. 

foams if shaken, though the foam soon disappears when at rest. It has 
a peculiar, characteristic odor, which is more or less pronounced ac- 
cording to the degree of concentration, and is spoken of as aromatic or 
urinous. This odor is probably due to the presence of minute quanti- 
ties of volatile acids, phenylic, taurylic, damaluric and damalic acids. 
If the urine has become alkaline, it acquires a disagreeable, repul- 
sive, so-called ammoniacal odor, which is due to the presence of bacterial 
decomposition products (probably ammonia and phenols). When 
decomposition is pronounced, the odor is liable to become putrid. 
After ingestion of certain articles of diet and after taking different 
medicines, the urine emits a more or less characteristic odor. The 
peculiar odor after eating asparagus is said to be due to methyl- 
mercaptan. After the administration of oil of turpentine an odor not 
unlike violets is produced. The odor of copaiba, cubebs, and oil of 
sandalwood is communicated to the urine when these drugs are taken 
internally. An odor, at first not unlike sweet-brier, but soon becoming- 
very offensive, is present when the urine contains cystin. 

The solid constituents of normal urine are partly inorganic and 
partly organic. The total amount of solids voided with the urine 
in twenty-four hours is between 60 and 70 gm. The following table 
of Hammarsten gives the average amounts of solids voided by a healthy 
adult : 

1. Inorganic constituents less than 27.0 gm. 

Hydrochloric acid, HC1 about 9.35* 

Sulphuric acid, H 2 S0 4 2 . 50 

Phosphoric acid, P 2 5 2.50 

Nitric acid, HN0 3 less than . 10 

Sodium oxide, Na 2 7.90f 

Potassium oxide, K 2 3.00 

Ammonia, NH 3 0.70 

Calcium oxide, CaO . 30 

Magnesium oxide, MgO . 50 

Iron, Fe less than . 01 

2. Organic constituents 35 . gm. 

Urea about 30 . 

Uric acid 0.7 

Creatinin 1.0 

Hippuric acid 0.7 

Other organic constituents a total of 2.6 

These consist of purin bodies, oxalic, oxaluric, lactic, carbamic, 
and succinic acids, carbohydrates, glycerophosphoric acid, ethereal 
sulphates of phenol, cresol, pyrocatechin, indoxyl and skatoxyl, 

* As sodium chloride, 15 gm. f As sodium chloride, 15 gm. 



PHYSICAL AXD CHEMICAL PROPERTIES. 



17 



pigments, chromogens, ferments, and a few other non-important 
substances. 

The constituents vary considerably under normal conditions, and 
according to Parkes the composition of normal urine is as follows: 

AMOUNTS OF URINARY CONSTITUENTS ELIMINATED IN TWENTY- 
FOUR HOURS. 



Constituents 


Average man, weight 
66 kilograms. 

Grams 


Per kilogram of 
body- weight. 

Grams 


Water 


1500.00 

72.00 

33.18 

0.55 

0.40 

0.91 

10.00 
2.01 
3.16 
7-8.00 
0.77 
2.50 

11.09 
0.26 
0.21 


23 . 000 


Total solids 


1.100 


Urea 

Uric acid 


0.500 
008 


Hippuric acid 

Creatinin 


0.006 
014 


Pigments and other organic sub- 
stances - 


0.151 


Sulphuric acid 

Phosphoric acid 

Chlorin 

Ammonia 

Potassium 

Sodium 

Calcium 

Magnesium 


0.030 
0.048 
0.126 



The urinary pigments or coloring matters found in urine are uro- 
chrome, which gives the yellow color to the urine; haematoporphyrm, 
urohaematin, uroerythrin, uroindican, and urobilin. The latter is 
not, as a rule, found in freshly voided urine, but is always found after 
standing; hence it is present as a chromogen, named urobilinogen. 
All of these coloring matters are not necessarily present in every urine, 
the three important ones being urochrome, hsematoporphyrin, and 
urobilin. 

The gaseous constituents are carbonic acid, nitrogen, and oxygen, 
the latter in very small amount only. 

Transparency and Changes upon Standing. — Normal, freshly voided 
urine is always perfectly clear, but if left at rest for a few hours a 
cloudy sediment, more or less pronounced, forms, and is usually more 
marked in the urine of females. This sediment, which at first usually 
floats in the centre of the urine and gradually settles at the bottom, is 
known as nubeada, and disappears entirely upon shaking. It con- 
sists of mucus, with a few flat epithelia from the bladder, and, in the 
urine of females, from the vagina. In addition to these features, 



18 URINARY ANALYSIS AND DIAGNOSIS. 

epidermal scales from the prepuce and nymphaB will always be found, 
and spermatozoa may also be present. At the time of menstruation 
the urine is red and contains numerous red blood corpuscles. A normal 
acid urine may, after a few hours, precipitate some amorphous urates, 
then a few uric-acid crystals, and occasionally a small number of 
calcium-oxalate crystals. 

After the urine has remained standing for one or more days, 
bacteria develop, their number and rapidity of development depend- 
ing upon the temperature. In warm weather they may appear in the 
course of a few hours. In highly acid urine conidia and mycelia not 
infrequently form, though cocci and bacilli may also be found. Sac- 
charomycetes or yeast fungi may similarly develop in acid urine; 
these are most commonly, though not exclusively, seen in urine con- 
taining sugar. In alkaline urine fission fungi — both cocci and bacilli — 
are seen in large numbers. When ammoniacal decomposition of the 
urine sets in, the urea is gradually transformed into ammonium car- 
bonate through the activity of the micro-organisms. Such a urine 
becomes turbid or opaque from the presence of the fission fungi and 
precipitated phosphates. The deposit of amorphous urates now be- 
comes transformed into ammonium urate, while uric-acid and calcium- 
oxalate crystals disappear, and characteristic crystals of triple phos- 
phates develop. 

Under Pathological Conditions the urine may be passed as a 
cloudy liquid of varying consistency. The highest degree of viscidity 
is usually found in chronic cystitis, when the urine, being strongly 
alkaline and decomposing in the bladder, appears as a viscid, stringy, 
muco-purulent mass, with a repulsive ammoniacal odor; it contains 
a varying number of bacteria and a large amount of phosphates. In 
suppurative conditions the urine often has a peculiarly offensive, 
putrid odor. In severe cases of diabetes a sweet or fruity odor of 
acetone is often imparted to the urine, while a fecal odor is present in 
cases of fistula communicating with the intestines. 

The color of the urine will be greatly changed by an increase or de- 
crease of the normal coloring matters or the abnormal presence of 
biliary matter. Biliary pigments color the urine reddish-brown, 
brown, or greenish, and give to it a greenish-yellow foam. When the 
urine is mixed with blood it will be more or less dark colored. In 
febrile conditions it is, as a rule, highly acid in reaction, and has a 
reddish or reddish-brown color, partly due to an excessive amount of 
urates, and partly to the presence of uroerythrin. The same may be 
the case in many slight disturbances of the system. In the rare cases 
of chyluria the urine is milky in character. 



PHYSICAL AND CHEMICAL PROPERTIES. 



19 



The following table modified from Halliburton shows the nature 
and origin of the chief variations in the color of the urine: 



Color 



Cause of coloration 



Pathological condition 



Xearlv colorless 



Light or straw yellow . 



Highly colored. 



Milky 



Orange . 



Red or reddish 



Dilution or diminution of 
normal pigments 



Polyuria 



Nervous conditions, hydr- 
uria, diabetes insipidus, 
chronic interstitial ne- 
phritis, anemia, chlorosis 



Diabetes mellitus 



Concentration, uroerythrin 



Pus corpuscles 
Fat globules 



Excreted drugs, santonin, 
chrysophanic acid. 



Haematoporphyrin, un- 
changed haemoglobin, pig- 
ments in food (logwood, 
madder, bilberries, fuch- 
sin), antipyrin, sulfonal, 
trional, antifebrin 



Acute fevers, inflamma- 
tions, l^peraemia of 
kidnevs 



Purulent diseases of 
genito-urinary tract 
Chvluria 



the 



Haemorrhages or haemo- 
globinuria 



Dark, smoky 



Salol, guiacol, tannin, re- ! Alkaptonuria 
sorcin, alkapton 



Brown to brown-black 



Haematin 

Methaemoglobin 

Melanin 



Small haemorrhages 
Methaemoglobinuria 
Melanotic sarcoma 



Greenish-yellow, greenish- 
brown, approaching black 



Bile pigments, pyrogallic Icterus 
acid 



Dirt y green or blue . 



Methylene blue 

A dark blue scum on sur- 
face with a blue deposit, 
due to an excess of indigo- 
forming substances 



Cholera, typhus; seen es- 
pecially when the urine is 
putrefying 



Brown-yellow to red- Substances introduced into 
brown, becoming blood- the system, contained in 
red upon addition of senna, rhubarb and cheli- 
alkalies donium 



20 URINARY ANALYSIS AND DIAGNOSIS. 

The sediment may be considerably increased. An increased amount 
of uric acid gives a red, so-called brick-dust sediment, which also ad- 
heres to the sides of the vessel, while an excess of amorphous urates 
gives a heavy, turbid, so-called clay- water sediment. The presence 
of inflammatory products, phosphates, or bacteria may produce a flaky 
or granular sediment, and the presence of filaments or threads from 
the urethra or prostate gland in cases of urethritis and prostatitis a 
flocculent sediment. A ropy sediment is present in cases of chronic 
cystitis when the urine decomposes in the bladder, and a purulent 
sediment in suppurative conditions of the genito-urinary tract. 

The amount of urine varies considerably, in many pathological 
conditions. Increased quantity of urine is known as polyuria, 
diminished quantity as oliguria, partial or complete suppression as 
anuria. Polyuria must be distinguished from poUakiuria, which 
signifies frequent urination without regard of the quantity of urine 
voided. The excretion of an increased amount of urine with normal 
or reduced total solids for twenty-four hours is known as hydruria. 
The urine is increased in amount in most cases of diabetes mellitus, 
and its specific gravity is generally high — 1.030, 1.040, or more — 
although the color is frequently pale, even straw yellow. In some cases 
of diabetes, however, the specific gravity may not only be normal, but 
below normal — 1.015, 1.012, or less — and still a large amount of sugar 
may be present. The quantity of urine is also considerably increased 
in diabetes insipidus, in hysteria, convulsions, convalescence from 
different acute inflammatory diseases, hypertrophy of the heart, and 
chronic nephritis, especially cirrhosis of the kidney. Patients suffer- 
ing with cirrhosis constantly void large quantities of pale, at times 
colorless urine, with greatly decreased solid constituents and a specific 
gravity frequently below 1.010. 

The amount of urine is decreased in acute inflammations of the 
kidney, as well as in acute inflammatory conditions of the other organs 
and acute fevers. The urine may be more or less completely sup- 
pressed in ursemia, in the last stages of cholera and yellow fever, in 
rapidly progressive forms of anaemia, in shock due to internal injuries, 
after catheterization, and in obstructive diseases of the urinary pas- 
sages. In persons suffering from nephritis it may be suppressed after 
the administration of ansesthetics. 

Determination of Specific Gravity. — The simplest method of as- 
certaining the specific gravity is by means of the urinary hydrometer 
or urinometer (see Fig. 6), which, if carefully constructed, will be 
sufficiently accurate for all practical purposes. If tested with distilled 
water, such a urinometer will sink to the 1.000 mark at the average 



PHYSICAL AND CHEMICAL PROPERTIES. 



21 




temperature of the room. The specific gravity of a specimen should 
be taken only after it is cooled; otherwise errors will result. The glass 
cylinder supplied with the instrument should be fluted, so that the 
latter will not cling to the side of the glass. The test is made as fol- 
lows: Fill the cylinder four-fifths full of urine, removing the froth, if 
any is present, with filtering paper. Place the urinometer in the 
urine, being careful not to allow it to come in contact with the walls 
of the vessel. Bring the eye on a level with the surface of the urine, 
and read the corresponding division of the urinometer, but not the 
upper rim of the fluid, raised a little by capillary 
attraction. Touch the stem, causing the urino- 
meter to sink slightly in the fluid and, after it has 
come to rest, read again. 

If the amount of urine is small, dilute the 
specimen with one, two, or even three volumes of 
water; test as before directed, and multiply the 
number of the division mark by the number of 
volumes used in the process of dilution. For ex- 
ample, if two volumes of water have been added 
to one volume of urine, thus making three volumes 
in all, and the urinometer stands at 1.006, the 
real specific gravity of the original urine is 1.018. 
The solid materials upon which the specific 
gravity depends, which were dissolved in one volume, are, after dilu- 
tion, dissolved in three volumes, and the specific gravity is therefore 
only one-third of the original. 

As indicated above, the temperature is important, and the specific 
gravity should never be taken when the urine is freshly voided. The 
urinometers are graduated at a temperature of about 15.5° to 17.5° C. 
(60° to 63.5° F.). If the urine is warmer than this temperature, one- 
third of a urinometer degree should be added for each degree of urine 
temperature; if colder, one-third of a urinometer degree should be 
subtracted for each degree of urine temperature. A temperature scale 
is found on many urinometers, or a thermometer is supplied with the 
instrument.* 

More accurate methods for determining the specific gravity are the 
py knometer and the Mohr-Westphal balance. The latter is useful 
only in most exact work. With the pyknometer exact estimations 
can also be obtained. The principle of this method depends upon 
the determination of the weight of a definite volume of urine as com- 
* Squibb's urinometers, which are used considerably in this country, are stand- 
ardized at 25° C. or 77° F., a more convenient temperature for clinical work. 



Fig. 



-Urinometer. 



22 



URINARY ANALYSIS AND DIAGNOSIS. 



pared with that of the same volume of distilled water at exactly the 
same temperature, the specific gravity being deduced from the ratio 
of these two weights. Neither of these two methods is sufficiently 
simple for general practical work. 

For the estimation of the specific gravity in the smallest amounts 
of urine, Saxe has devised a special form of hydrometer, which he calls 
the urinopyknometer. This hydrometer determines the specific gravity 
of about 3 c.c. of urine, and where small quantities of urine only are 
available, as in infants or after catheterization of the ureters, it is of 
considerable value and of a fair degree of accuracy. 

Saxe's urinopyknometer (see Fig. 7) consists of a small flask with a 
well-fitting glass stopper, the head of which bears a tiny bead of mer- 
cury. The flask is attached to a small spherical bulb, 
over which is the stem of the instrument, graduated 
in reverse order as compared to the ordinary urino- 
meter — that is the mark 1,060 is at the top of the stem 
and the mark 1,000 at the bottom. When the flask 
is filled with distilled water up to the mark, and when 
the instrument is closed and immersed in a glass 
cylinder filled with distilled water, it reads 1,000 at 
the level of the distilled water. When urine is 
poured into the flask to the same mark, the instru- 
ment sinks in distilled water in proportion to the 
specific gravity of that urine, which is then read on 
the scale. The same precautions in reading must be 
taken as with the urinometer, and the flask must be 
perfectly clean and dry. The urine must be poured 
in accurately with a small dropper until it reaches the 
mark, so that the lower meniscus touches it as the 
flask is held at the level of the eye. 

Determination of Solids. — To determine the 
amount of solids present in the urine voided dmv 
ing twenty-four hours, for practical work, the exact 
quantity passed during this time, as well as its specific 
Saxe's gravity, must be known. The specific gravity is di- 
rectly dependent upon the amount of solids in solu- 
tion, a diminution of the solids giving a lower, an 
increase a higher, specific gravity. 

For clinical purposes the amount of total solids voided can be 
approximately determined by multiplying the last two figures of the 
specific gravity by the coefficient of Haeser, which is 2.33; this gives 
the number of grams of solid matter in 1,000 c.c. of urine. This 




Fig. 7 
Urinopyknome 

TER. 



PHYSICAL AND CHEMICAL PROPERTIES. 23 

number, multiplied by the number of cubic centimetres passed in 
twenty- four hours and divided by 1,000, will give the amount of solid 
constituents eliminated during that time. 

Suppose, for example, 1,500 c.c. of urine were passed in twenty-four 
hours, of a specific gravity of 1.020. To estimate the amount of solids, 
multiply the last two figures, 20, by the coefficient, 2.33, and by 1,500, 
and divide by 1,000, thus: 

20X2.33X1,500 



1,000 



= 69.90 gm. 



Or, 20 X 2.33 X 1.5 = 69.90. Again, if 1,250 c.c. of urine were passed, 
of a specific gravity of 1.018: 18 X 2.33 X 1.25 = 52.425 gm., the 
total amount of solids voided in twenty-four hours. 

Valuable conclusions as to the amount of solids may thus be ob- 
tained from the specific gravity in a very short time. In diabetes, for 
instance, the quantity of urine voided being large and of a high specific 
gravity, the amount of solids is considerably increased; in inflamma- 
tions of the kidney, on the other hand, where the quantity of urine 
is decreased and the specific gravity is low, the amount of solids is 
diminished. No deductions, however, can be drawn from the amount 
of total solids as to the amount of any particular solid, especially 
urea. Although urea constitutes from forty to fifty per cent of all 
the sglids excreted in healthy individuals, in pathological conditions 
the proportions of urea and the other solid constituents often vary to a 
considerable degree. 

The coefficient of Haeser was calculated on the basis of the specific 
gravity determined at a temperature of 15° C, and, although in 
universal use, is claimed to be inaccurate for conditions existing in 
America. Long therefore uses the coefficient 2.6, which was deter- 
mined for urine the specific gravity of which was taken at a tem- 
perature of 25° C. To determine the approximate number of grains 
of solids in each fluidounce of urine, multiply the last two figures 
of the specific gravity by Haines' coefficient, which is 1.1. When this 
figure is multiplied by the total number of ounces voided during 
twenty-four hours, the excretion of total solids in grains is obtained. 



CHAPTER IV. 

NORMAL CONSTITUENTS. 

A. ORGANIC. 

Total Nitrogen. — The total output of urinary nitrogen is the best 
index of the metabolism of the proteins. This output depends upon 
the amount of nitrogen taken into the body with the food, as well as 
upon the degree of tissue metabolism. Normally the proportion be- 
tween the intake and the output of nitrogen is equal, so that a healthy 
person is in a condition of nitrogenous equilibrium. Of the total 
nitrogen eliminated from the body between ninety-three and ninety- 
five per cent is excreted in the urine and the remaining five to seven 
per cent in the faeces. Minute amounts escaping from the skin and 
the lungs can be neglected. 

The normal amount of total nitrogen in the urine of a person upon 
a mixed diet varies between 10 and 16 gm. (150 to 250 grains) in 
twenty-four hours. The total nitrogen output is increased as a re- 
sult of increased protein metabolism. The amount is greater after a 
heavy protein diet, reaching its maximum a few hours after such a 
meal, also after exercise on account of increased muscular activity, 
after hot baths, and after drinking considerable quantities of water, 
since with an increase of water excretion that of nitrogen is also in- 
creased. The total nitrogen output is diminished on a low nitrogen 
diet, and also on one rich in carbohydrates and fat; when the water 
excretion is reduced on account of sweating; during pregnancy, and 
after the administration of certain drugs, especially quinine and 
opium. 

Pathologically the nitrogen output is especially increased in acute 
febrile infections, but also in cachectic conditions in which there is a 
rapid waste of tissues; in diabetes mellitus and insipidus; in all con- 
ditions in which a diminished absorption of oxygen occurs, such as 
dyspnoea and severe haemorrhage; after various poisons such as phos- 
phorus, arsenic, antimony and other metallic poisons; finally during 
the absorption of an exudate or a transudate. It is diminished in 

24 

i 



NORMAL CONSTITUENTS. 25 

convalescence from acute and chronic diseases; in conditions of de- 
pressed vitality, as well as in all conditions in which the absorption 
of the proteins is interfered with. During the formation of an exu- 
date or a transudate, or whenever the water output is diminished the 
nitrogen is diminished; also in cases of nephritis due to a renal in- 
sufficiency and to the associated oedema; finally just before death from 
any cause. 

The nitrogenous constituents of the urine are urea, ammonia, 
uric acid, purin bases, creatinin, and the so-called " undetermined 
nitrogen." The latter is made up of different substances present in 
variable, though small amounts; it includes hippuric acid, the amino- 
acids, oxy-proteic and alloxy-proteic acids, and allantoin. The 
distribution of these various nitrogenous products, called the "Nitro- 
gen partition of the urine," varies according to the diet. This dis- 
tribution among urea and the other nitrogenous constituents depends, 
according to Folin and others, upon the absolute amount of the total 
nitrogen excreted. It was found that a decrease in the total nitrogen 
excretion was always accompanied by a decrease in the percentage of 
urea. While in persons upon a mixed diet between eighty and ninety 
per cent of the total nitrogen excreted is urea, upon a nitrogen-free 
diet no more than sixty to sixty-five per cent appears in the urine 
as urea. This reduction in the uea excretion upon a nitrogen-free 
diet is made up by an increase in the other factors, especially the 
ammonia and creatinin, both of which are relatively increased by per- 
centages, although they may be absolutely diminished. According to 
the same authors, urea is the only one of the nitrogenous excretions 
which is both relatively and absolutely diminished as a result of 
decreased protein metabolism. Cases have been reported in which less 
than twenty per cent of the total nitrogen appeared in the urine as 
urea. 

Considerable clinical value has also been placed upon the nitrogen 
partition in pregnancy, in which there is normally in many cases a 
disturbance of metabolism, diminishing the urea and increasing the 
ammonia and the undetermined nitrogen. The amount of the latter 
is claimed to be especially high when toxic symptoms of any kind 
develop during pregnancy, so that in all such cases a careful deter- 
mination of the different nitrogenous ingredients of the urine may be 
helpful to the clinician. 

The method used for the estimation of total nitrogen is that of 
Kjeldahl, which, however, is too complicated for ordinary clinical work, 
so that the clinician usually relies upon the estimation of urea, ammo- 
nia and uric acid. KjeldahPs method is based upon the fact that 



26 URINARY ANALYSIS AND DIAGNOSIS. 

the nitrogenous constituents of the urine, when heated with con- 
centrated sulphuric acid, are oxidized to ammonium sulphate. The 
latter is then decomposed by means of a caustic alkali and distilla- 
tion, and the gaseous ammonia thus given off is collected in a known 
quantity of standard solution of an acid. The solution is then ti- 
trated with a standard alkali, and the difference between the acidity 
thus shown and its original acidity furnishes an index of the ammonia 
absorbed, and consequently of the total nitrogen. Every cubic centi- 
metre of tenth normal sulphuric acid, used by the ammonia liberated 
in the distillation, represents 0.001401 gm. of nitrogen. 

Urea. — Urea or carbamide (CON 2 H 4 ) is the chief organic constitu- 
ent of urine and the most important nitrogenous waste product found 
in urine. The greater portion of nitrogen taken into the system as 
food is excreted by the kidneys in the form of urea, which substance 
represents between eighty and ninety per cent of the total nitrogen of 
the urine, with the person upon a mixed diet; upon a nitrogen-free 
diet it represents only between sixty and sixty-five per cent. The 
amount of urea excreted varies greatly under different physiological 
conditions, ranging between 20 and 35 or 40 gm., or approximately 
between 310 and 620 grains in twenty-four hours; this represents from 
forty to fifty per cent or more of all the solid ingredients voided. As 
urea is the most abundant solid of urine, it influences the specific 
gravity most, which latter will therefore give an approximate idea of 
an increase or decrease of urea. A specimen of normal urine, with a 
specific gravity of 1.020 and voided in a quantity of about fifty ounces 
(1,500 c.c), will contain about 450 or 500 grains of urea (28 to 31 gm.), 
or 9 to 10 grains to the ounce, or about two per cent. 

Normally the amount of urea excreted varies greatly with the diet ; 
it is most abundant after an exclusive meat diet, less abundant after a 
mixed, and least abundant after a strictly vegetable diet. It is in- 
creased after muscular exercise and mental activity. Pathologically it 
is increased in acute fevers, owing to increased tissue metabolism, and 
in diabetes, in the latter condition sometimes to a considerable degree. 
It is decreased in diseases of the liver — the liver being the chief seat 
of the formation of urea — in diseases of the kidney, and in chronic 
affections impairing the vitality of the patient. 

Urea is frequently decreased in normal pregnancy. It is a common 
and undoubtedly commendable practice to examine the urine for urea 
at stated intervals during pregnancy. Unfortunately, the many 
different factors which should be taken into account, such as diet, 
exercise, and the condition of the gastro-intestinal tract, are frequently 
overlooked, and unnecessary anxiety is caused by a continued di- 



NORMAL CONSTITUENTS. 



27 



minution in the amount of urea excreted. In these cases too much 
significance should not be attached to the decreased amount of urea 
alone, but all the important chemical tests, as well as thorough micro- 
scopical examination, must be resorted to before alarming the patient 
or her relatives. 




Fig. 8. 



-Crystals of Urea (Upper Half) and Nitrate of Urea (Lower 
Half) (X 200). 



Urea is always held in solution and can never be found under the 
microscope without chemical means. It crystallizes in the form of 
colorless quadrilateral plates or prisms, and in needles of varying sizes. 
It is readily soluble in water and alcohol, but is insoluble in ether. 
Urea can easily be detected as nitrate of urea by placing a few drops of 



28 URINARY ANALYSIS AND DIAGNOSIS. 

urine upon a glass slide, adding a drop of nitric acid, warming the slide 
carefully, and placing it aside to crystallize. Under the microscope 
more or less regular rhombic or hexagonal plates, either single or 
overlapping each other, may now be found. These plates have a 
little color and are perfectly characteristic (see Fig. 8). With oxalic 
acid it forms oxalate of urea, in the form of flat or prismatic crystals. 

Quantitative Tests. — The quantitative tests for determining the 
exact amount of urea present in the urine are numerous, but more 
or less complicated. The clinically available methods are by no means 
accurate, but sufficiently so for general practical work. The most 
inaccurate is the approximate estimation of urea by means of the 
specific gravity. As urea is the most abundant solid constituent of 
the urine, it influences the specific gravity most, which latter runs 
closely parallel to the amount of urea, provided that the chlorides are 
normal, no sugar is present, and the urine contains no albumin, or a 
small amount only. In such cases the percentage of urea practically 
parallels the last two figures of the specific gravity; a specific gravity 
of 1,020, for instance, conforms with the presence of 2 per cent of 
urea; one of 1,018 with 1.8 per cent; of 1,024 with 2.4 per cent; and of 
1,009 with 0.9 per cent. The variations in the majority of such cases 
are rarely more than 0.1 per cent in either direction. Such rough 
estimations should, however, never be made where the entire twenty- 
four hours' urine is available, but can be made with single voidings, 
since neither the specific gravity nor the amount of urea of a single 
voiding, or even that of the night and morning urine combined can 
give any idea of the correct readings for twenty-four hours. An in- 
crease or diminution in the amount of the chlorides present, however, 
materially influences the specific gravity. 

Hypobromite Method. — The best and simplest of the clinically 
available methods is the hypobromite method, introduced by Knop, 
the principle of which depends upon the fact that, when ,urea comes in 
contact with an alkaline sodium-hypobromite solution, it is decomposed 
into nitrogen, carbon dioxide, and water, according to the following 
equation: 

CO(NH 2 ) 2 + 3NaBrO = 3NaBr + 2H 2 + C0 2 + N 2 . 

The carbon dioxide which develops is absorbed by the sodium hy- 
droxide, while from the volume of nitrogen liberated the amount of 
urea can be calculated. 

The quickest way of carrying out this method is by means of Dore- 
mus' ureometer. The hypobromite solution necessary for this test 
does not keep well, and it is therefore best to keep the bromine and the 



NORMAL CONSTITUENTS. 



29 



caustic-soda solution separate. Have on hand a solution of sodium 
hydroxide — 100 gm. of caustic soda to 250 c.c. of water (or four ounces 
to ten of water) — and the bromine, in separate bottles. To prepare 
the solution for immediate use, take 10 c.c. of the sodium hydroxide 
solution and add 1 c.c. of bromine; mix thoroughly, dilute with 11, 
12, 13 or 14 c.c. of water, and the solution is then ready for use. A 
glass graduate, of a capacity of 25 c.c, will be found the most con- 
venient for this purpose. 

Instead of using pure bromine, which is disagreeable to handle, 
Rice's solutions may be substituted and give good results. The 




Fig. 9. — Doremus' Ueeometer. 



bromine is replaced by a solution composed of one part each of bromine 
and potassium bromide and eight parts of water. The two solutions 
to be kept separately are (1) caustic soda, 100 gm., distilled water, 
250 c.c; (2) bromine, 30 c.c, potassium bromide, 30 c.c, distilled 
water, 240 c.c; these solutions keep indefinitely. For immediate use, 
take 5 c.c. of each of these solutions, mix, and dilute with 10, 12 or 
14 c.c. of water. In both cases fill the bulb of the ureometer with the 
solution and proceed as^stated below. 

Doremus' apparatus (see Fig. 9) consists of a bulb and graduated 
tube and a small curved nipple-pipette to hold 1 c.c. of urine. The 
bulb of the ureometer is filled with the hypobromite solution, and by 
inclining the tube the long arm is filled to the bend in the bulb. By 
means of the nipple-pipette 1 c.c of urine is drawn up, the pipette 



30 



URINARY ANALYSIS AND DIAGNOSIS. 



passed through the bulb of the ureometer as far as it will go in the bend, 
and the nipple compressed gently and steadily. The urea instantly de- 
composes, and the bubbles of nitrogen rise in the long arm of the 
instrument, while the displaced liquid flows into the bulb. The 
decomposition of urea is complete in from five to twenty minutes, and 
the graduation on the tube indicates the quantity of urea in 1 c.c. of 
urine. Two forms of the instrument are furnished — one graduated 
to read fractions of a gram to the cubic centimetre of urine, the range 
being from 0.01 to 0.03 gm.; to obtain the percentage, multiply the 
number of divisions on the tube by 100; thus, 
0.02 gm. to the cubic centimetre is two per cent 
of urea. The other form of the instrument is 
graduated to show the number of grains of 
urea per fluidounce of urine. 

Hinds' modification of the Doremus ap- 
paratus (see Fig. 10) is more convenient and 
more accurate than the original form, as it 
obviates the use of a pipette. The amount of 
urine is measured more exactly, being intro- 
duced into the graduated small tube and the 
flow controlled by the stopcock. 

In using the Doremus' ureometer, the 
urine should theoretically be free from both 
albumin and sugar. Practically, however, 
these substances need not be removed, since 
the method never yields accurate results. 
When more than a trace of albumin is present in the urine, a dense 
froth collects in the ureometer tube while the urine is injected; 
this froth forms first in the upper portion of the tube, but, when the 
amount of albumin is large, soon becomes disseminated throughout 
the entire tube. It settles slowly, so that frequently the percentage 
of urea can not be read until after twenty minutes or half an hour. 

For all clinical purposes the above method is perfectly sufficient 
and no other is required. For accurate scientific work, however, more 
elaborate methods are necessary, and of these the method of Morner 
and Sjoqvist gives the most accurate results. If urine is treated with 
a mixture of barium chloride and barium hydrate and then allowed to 
stand under alcohol-ether for twenty-four hours, all the nitrogenous 
constituents of the urine are precipitated, while the urea is dissolved 
in the alcohol-ether. The urea solution is filtered off and the nitrogen 
content of the filtrate determined by Kjeldahl's nitrogen method, 
which consists in converting all the nitrogenous constituents of the 




Fig. 10. — Hinds' Modifica- 
tion of Doremus' Ure- 
ometer. 



NORMAL CONSTITUENTS. 31 

urine into ammonia by boiling the urine with concentrated sulphuric 
acid. The ammonia combines with the sulphuric acid to ammonium 
sulphate; caustic soda is then added to liberate ammonia gas, which 
is distilled off into a known amount of sulphuric acid. The amount of 
uncombined sulphuric acid is next determined and subtracted from the 
known total. The difference equals the amount neutralized by am- 
monia, and from this factor the amount of urea is calculated. The 
method is too complicated for clinical work. 

Urease Methods. — In 1913 E. K. Marshall introduced a new method 
for the determination of urea, which is based on a different principle 
and which is considered to be more accurate than the hypobromite 
method, even though it is not quite as simple. He took advantage of 
a discovery by Takeuchi in 1909, that an aqueous extract of soy bean, 
(Glycine hispida) contains a ferment which converts urea into ammo- 
nium carbonate. This enzyme is called urease, and its action is not 
interfered with by the presence of either protein or glucose. Later 
urease was also found in other beans, notably the Jack bean (Cana- 
valia ensiformis.) It can be obtained in the form of a soluble dry 
powder or in the form of soluble tablets. 

Different methods have been described, the simplest being the so- 
called " Clinical Method" of Marshall, which has been somewhat 
modified in accordance with the kind of urease employed. In the 
execution of this method, measure into each of two 200 c.c. Erlenmeyer 
flasks 5 c.c. of the urine to be examined and about 100 c.c. of distilled 
water. To one of these flasks add 1 c.c. of a 10 per cent, solution of 
urease or 1 tablet and to each a few drops of toluene. Stopper both 
flasks with corks, and allow them to remain at room temperature for 
at least eight hours, or in the incubator at 37° C. for three hours. The 
time required for complete hydrolysis of the urea depends on the 
quantity of urine used, the concentration of the urea, the amount of 
enzyme present and the temperature of action. The velocity of the re- 
action is approximately twice as rapid at 35° C. as at 25° C, and directly 
proportional to the enzyme concentration within certain limits. If 
rapid determinations are desired 1 c.c. of urine only should be used and 
one or two tablets of Urease added. Dilute with 100 c.c. of water 
and digest between 40 and 50° C. for 15 to 30 minutes. At the end 
of the proper time titrate the contents of each flask to a distinct pink 
color with decinormal hydrochloric acid, using a few drops of 0.5 per 
cent methyl orange solution as indicator. The amount of acid re- 
quired to neutralize the urease-treated specimen, less the amount 
required for the control, will give the urea content estimated upon its 
equivalent in ammonium carbonate. The difference between the 



32 URINARY ANALYSIS AND DIAGNOSIS. 

number of c.c. of decinormal acid used in the two titrations, multiplied 
by the factor 0.06 gives the percentage of urea in the urine. From 
the percentage the 24-hour elimination can be calculated. 

A more accurate method is that of Van Slyke and Cullen, which 
consists in treating the urine sample with urease, aerating the ammonia 
formed into fiftieth-normal acid and titrating back the excess acid. 
A suction-pump, such as can be attached to any tap with fair water- 
pressure, is required. This method is somewhat too complicated. 

Ammonia. — Ammonia (NH 3 ) is next to urea the most important 
nitrogenous product of protein metabolism, and is for this reason placed 
with the nitrogenous bodies, although it chemically belongs to the 
class of inorganic constituents. It is constantly present in small 
amounts in normal urine, varying from 0.4 to 1.2 gm. (7 to 20 grains), 
with an average of 0.7 to 0.8 gm. in twenty-four hours on a mixed diet. 
This represents from 3.5 to 5 per cent of the total nitrogen output. 
It is present in combination with various acids and represents a 
portion of the nitrogen which has not been transformed into urea, but 
has been utilized to combine with acid substances formed in the 
protein metabolism of the body. An increased production of acid in 
the system leads to an increased elimination of ammonia. 

Under normal conditions the relation of ammonia to the total 
nitrogen is a fairly constant one, and varies with the diet. A pro- 
nounced reduction of total nitrogen, however, is, according to Folin, 
always accompanied by a relative increase in the ammonia. The term 
"ammonia coefficient" is sometimes used to denote the percentage 
of ammonia nitrogen with reference to the total nitrogen. Copious 
water drinking increases the ammonia output. 

In diseased conditions the elimination of ammonia is increased in 
oxygen starvation; in febrile conditions; in diabetes mellitus where 
diacetic acid and /5-hydroxybutyric acid are found in the urine in 
combination with the ammonia; in diseases of the liver when the for- 
mation of urea is interfered with, such as cirrhosis, carcinoma, and 
acute yellow atrophy; in uremia; in acid intoxications generally; and 
in the toxaemias of pregnancy, especially in cases of pernicious vomit- 
ing The elimination is diminished in many cases of nephritis, and 
in some cases of carcinoma of the stomach. 

For the quantitative determination of ammonia a simple method 
is the formalin method. This depends upon the fact that free am- 
monia, when treated with formaldehyde, combines with it, with the 
formation of hexamethylen-tetramin, the ammonia being liberated 
from its salts by means of sodium hydroxide. The method is the fol- 
lowing: Dilute 20 c.c. of urine with 60 or 100 c.c. of water, add a few 



NORMAL CONSTITUENTS. 33 

crystals of neutral potassium oxalate and a few drops of a one per 
cent alcoholic^olution of phenolphthalein. A decinormal solution of 
sodium hydroxide (4 gm. in litre), is added slowly from a burette, 
while stirring, until a permanent pink color appears. Then add 2 
c.c. of a forty per cent solution of formaldehyde, which has been pre- 
viously neutralized. When the pink color has disappeared, pass 
in more of the decinormal sodium hydroxide, until the color returns. 
Each cubic centimetre used in this second titration represents 0.0017 
gm. of ammonia in 20 c.c. of urine. Knowing the amount of urine 
voided in twenty-four hours, the total daily ammonia can be easily 
calculated. 

Uric Acid. — Uric acid (C5H4N4O3), like urea, is a nitrogenous 
product, although it is normally found in urine in small amount only, 
0.3 to 1.5 gm. (5 to 25 grains) being the amount usually voided in 
twenty-four hours; the average is 0.7 gm. Like urea, the amount 
excreted is dependent upon the diet, and under normal conditions 
is in direct proportion to the amount of urea excreted; the proportion 
is 1 of uric acid to 45, 50 or 60 of urea. 

Uric acid is probably formed chiefly in the liver and to a small 
degree in the spleen, but not in the kidneys, being only excreted by the 
kidneys. Recent researches tend to show that it is derived from the 
nucleins, the chief chemical constituent of all cell nuclei; foods rich in 
nucleins give rise to the formation of uric acid. Its excretion is in- 
creased by a diet rich in protein matter, especially with diminished 
exercise or sedentarj^ habits; in acute fevers; diseases of the lungs and 
heart accompanied by dyspncea; abdominal tumors which impede 
respiration; rheumatism; in severe blood diseases, especially leukaemia, 
in which there is a disintegration of the nuclei of the blood corpuscles. 
Its increase in gout has been rendered doubtful by recent investigations, 
as it has been found that such an increase does not always take place. 
After the administration of certain drugs, such as salicylates, lithium, 
and alkaline citrates, the elimination may also be increased. Uric acid 
is diminished by a vegetable diet ; in chronic kidney diseases and other 
diseases in which the amount of urea is decreased; after the adminis- 
tration of different drugs, such as quinine, antipyrin, caffeine, iron, 
and lead. 

Pure uric acid is a white, odorless substance, feebly soluble in 
water, insoluble in alcohol and ether, readily soluble in glycerin and 
alkalies. It is not acid in reaction when tested with litmus paper. 
It crystallizes in urine in many different forms, almost invariably of 
yellow or yellowish-red color; the difference in its appearance under 
the microscope is due to the degree of acidity of the urine, the con- 



34 URINARY ANALYSIS AND DIAGNOSIS. 

centration, the amount of pigments, the temperature, and the rapidity 
of the process of crystallization. 

Under ordinary circumstances uric acid does not appear in the 
urine in a free condition, but always in combination with bases, such 
as sodium and ammonium, in the form of urates; of these bases, some 
are acid, others neutral. When the urine is concentrated from want 
of a solvent, or when poor in mineral salts which also act as solvents, 
or when pigments are deficient, precipitation occurs promptly upon 
cooling of the urine, and this also takes place when the urine is highly 
acid; the acidity is quickly neutralized by the bases of the urates, 
thereby liberating the acid. The mixed precipitate in the urine is 
always colored by uroerythrin; the free acid most, the ammonium 
urate about as much, the sodium urate less. The sodium urate occurs 
in characteristic granular masses, having the appearance of moss; the 
ammonium urate as globular formations, at times with variously sized 
spicules. For the reasons stated above, the amount of uric acid in the 
urine should not be considered excessive from the fact of a deposit- 
forming upon cooling, as such a deposit may occur when the amount is 
small, and a true increase can be detected only by quantitative tests. 

The detection of uric acid is easy with the aid of the microscope, 
owing to the characteristic lozenge-shaped, rhomboidal, wedge- or 
whetstone-shaped, barrel-shaped, and comb-shaped, yellowish crys- 
tals. The urates can also be easily distinguished under the microscope. 

A simple test is the murexide test: A small portion of the sediment, 
or the residue after evaporation, is placed on a porcelain dish, a few 
drops of a strong solution of nitric acid are added, and the solution is 
carefully warmed. When dry, a few drops of ammonia are added, 
and a beautiful purple color at once appears, which soon spreads over 
the dish, and changes into violet upon the addition of caustic potash. 
The color disappears upon warming. 

In this test alloxan is formed by the addition of nitric acid to uric 
acid or urates, and, by continuing the addition of nitric acid, alloxantin 
forms; this combines with ammonia to form acid ammonium pur- 
purate, C 8 H 8 N 6 06, also called murexide. 

Another simple method for the detection of uric acid is the follow- 
ing: Place about 200 c.c. of filtered urine in a beaker, and acidulate it 
with 5 to 10 c.c. of concentrated hydrochloric acid; after stirring 
thoroughly, stand the vessel in a cold place for from eighteen to twenty- 
four hours. At the end of that time a deposit of uric acid crystals has 
usually appeared. 

For the quantitative estimation of uric acid a convenient method is 
Ruhemann's method, which, although it does not give accurate re- 



NORMAL CONSTITUENTS 



35 



suits, is simple and practical, and may be used for general clinical 
purposes to determine the approximate amount of uric 
acid. It depends upon the decolorization of an iodine 
solution by the uric acid with the aid of carbon disul- 
phide, and the measurement of the amount of urine which 
must be added to a definite amount of iodine solution to 
bring about the decolorization. For this test a gradu- 
ated tube with a glass stopper, Ruhemann's uricometer, 
25 cm. in length, is used (see Fig. 11). The reagents 
necessary are first, carbon disulphide, and second, an 
iodine solution composed of iodine, 0.5 gm., potassium 
iodide, 1.25 gm., absolute alcohol, 7.5 c.c, glycerine, 
5 c.c, distilled water, q.s. 100 c.c. 

Place carbon disulphide in the tube to the lowest 
mark S } so that the lower meniscus of the reagent touches 
the mark; then slowly add the iodine solution to the 
mark J, so that the upper part of the meniscus rests upon 
the mark, and enough urine, by means of a pipette, to the 
lowest number on the tube, 2.45. Insert the glass stop- 
per, mix the contents of the tube thoroughly, and then 
add more urine, drop by drop, mixing after each addi- 
tion. The carbon disulphide absorbs the iodine, becom- 
ing first copper-brown, then after the addition of more 
urine violet, purple, pink, pale pink, and finally milky 
white or porcelain-white. The end-reaction is shown by 
the pale pink color in the carbon disulphide; this, upon 
more shaking, assumes a porcelain-white appearance. 
This process requires from six to ten or fifteen minutes, as 
it is best to shake the tube for about fifteen seconds after 
each urine addition. The amount of uric acid is then read 
off directly from the scale on the right, which shows the 
number of parts of uric acid per 1,000 of urine, or grams 
per litre. The scale on the left shows the number of 
cubic centimeters of urine used; this scale, being of little 
importance, is omitted from some of the uricometers. 

If the urine contains very little uric acid, only half 
the amount of iodine solution should be used, the rest of 
the space to the mark J being filled with distilled water, 
the indicated amount on the tube being then divided by 
two. If, on the other hand, an excess of uric acid is 
present, twice the amount of iodine is used, ana the re- 
sult multiplied by two. 



Fig. 11 — 
Ruhemann's 
Ueicometer. 



36 URINARY ANALYSIS AND DIAGNOSIS. 

For this test the urine must be acid in reaction and should be free 
from sugar and albumin. The presence of sugar, however, interferes 
very little, if at all, with the result, nor does the presence of small 
amounts of albumin. When albumin is present in large amounts, 
it should first be removed by boiling, acidifying with acetic acid and 
filtering. Should the urine react alkaline, it must first be acidified 
with dilute acetic acid. 

Another method for the quantitative estimation of uric acid is 
that of Heintz. This method is the following: To 200 c.c of filtered 
urine free from albumin add 10 c.c. of concentrated hydrochloric acid; 
allow to stand for twenty-four to thirty-six hours in a cool place; col- 
lect the precipitated uric-acid crystals on a previously weighed filter 
and wash in cold distilled water. Dry the filter and uric-acid crystals 
in a desiccator and weigh. By subtracting the weight of the filter, 
the weight of the uric acid in 200 c.c. of urine is obtained. 

Purin Bodies. — The term purin bodies, is a collective name used 
for a group of bodies, which are derived from nucleins and found in 
urine. To this group belong uric acid, xanthin, methylxanthin, 
heteroxanthin, hypoxanthin, paraxanthin, adenin, guanin, epiguanin, 
carnin and episarcin. The most important of these substances next 
to uric acid is xanthin. With the exception of uric acid, all its members 
are basic, and are known as purin bases, alloxur bases, xanthin bases 
and nuclein bases. The relation between these bodies is a close one, 
and the differences between them but small. All originate in the 
theoretical purin " nucleus," of the formula C 5 N 4 , which yields purin 
by the addition of four atoms of H = C5N4H4. Purin plus one atom 
O = hypoxanthin, plus 2 = xanthin, plus O3 = uric acid, which is 
therefore best named tri-oxy-purin. If the amido group (NH 2 ) re- 
places one H in purin, amidopurin or adenin results, and this body plus 
O = guanin. 

There are two varieties of purin bodies in the urine; the one va- 
riety, known as "exogenous," is derived from the food and varies accord- 
ing to the character and amount of food taken, while the other variety, 
known as " endogenous," is derived from the decomposition of the 
nucleins of the tissue cells. These bases are found in the urine in 
minute amount only. Pathologically they are increased in nephritis, 
leukaemia, and acute yellow atrophy of the liver. 

Xanthin, the most important substance of this group, is chemically 
closely allied to uric acid, containing one atom less of oxygen (C 5 H 4 - 
N4O2) than uric acid. It crystallizes in the form of small, colorless, 
lozenge-shaped crystals or hexagonal plates, and differs from uric acid 
by its solubility in ammonia and hydrochloric acid as well as by heat. 



XORMAL COXSTITUENTS. 37 

After the addition of acetic acid under the cover glass the crystals 
retain their form. 

Creatinin. — Creatinin (C4H7N3O) is a normal constituent of urine, 
being excreted in small amount, from 0.6 to 1.2 gm. in twenty-four 
hours. It, as well as creatin (C4H9X3O2), which is occasionally found 
in normal urine, is derived from muscle tissue of the body and from 
meat taken as food, so that its amount is largely dependent upon the 
diet. Muscular activity increases the excretion of creatinin. Patho- 
logically it is increased in acute diseases, such as typhoid fever and 
pneumonia, also in diabetes, and is diminished in conditions of wasting. 

The simplest test is Jaffe's method, which consists in treating the 
urine with a few drops of a ten per cent picric-acid and a ten per cent 
sodium-hydroxide solution; if appreciable quantities of creatinin are 
present, the liquid at once turns red, which color remains for some 
time, but changes to yellow if glacial acetic acid be added. Glucose 
gives a similar red color, but only upon the application of heat. 

Another simple and even more sensitive test is Weyl's method. To 
a few cubic centimetres of urine in a test tube add a few drops of a 
weak sodium nitro-prusside solution and render the solution alkaline 
with sodium or potassium hydroxide. A ruby-red color immediately 
appears, which, after a few minutes, changes to an intense yellow. 

Hippuric Acid. — Hippuric acid (C9H9NO3), normally present in 
urine in small amounts only, is increased after the ingestion of different 
fruits, such as cranberries, plums, and prunes, as well as after the ad- 
ministration of different drugs, such as benzoic acid, salicylic acid, 
cinnamic acid, and oil of bitter almonds. Meat diet diminishes its 
excretion, and it is quite abundant in the urine of herbivorous, absent 
in that of carnivorous, animals. Pathologically it is increased in 
intestinal putrefaction and in fevers, but its clinical significance is 
small. It is formed by a union of benzoic acid and glycocoll in the 
kidney and intestines. 

Hippuric acid may be detected by boiling the urine with con- 
centrated nitric acid and evaporating to dryness. The residue heated 
in the test tube gives the odor of bitter almonds, due to nitrobenzol. 

Besides hippuric acid, the so-called undetermined nitrogen in- 
cludes the amino acids, oxyproteic and alloxyproteic acids and 
allantoin. 

Amino Acids. — Both mono- and di-amino acids are found in 
normal urine in minute quantities, when the nitrogen intake has been 
large. They are decomposition products of protein metabolism and 
are usually converted into urea in the liver. In all conditions in which 
the function of the liver is impaired, they are present in the urine in 



38 URINARY ANALYSIS AND DIAGNOSIS. 

larger amounts. The presence of the two mono-amino acids, leucin 
and tyrosin, has been especially associated with acute yellow atrophy 
of the liver and phosphoric acid poisoning, but they may be found in 
the urine in any pathological condition of the liver. The amino acids 
are also found in cases of pneumonia, especially during the absorption 
of the exudates, as well as in diabetes, gout, and leukaemia. 

Oxyproteic and Alloxyproteic Acids. — These acids are constant 
constituents of normal urine, derived from protein metabolism. Both 
contain sulphur, but are of little practical importance, although it has 
been claimed that they are accountable for Ehrlich's diazo-reaction. 

Allantoin. — Allantoin (C 4 H 6 N40 3 ) is a product of oxidation of 
uric acid. It is usually present in the urine in traces only, but is in- 
creased by a meat diet, especially one rich in nucleins. In the urine 
of new-born infants and during the first week of life it is more abun- 
dantly found, also not infrequently in women during pregnancy. 
Pathologically it is increased in cases of diabetes insipidus and hysteria, 
especially those associated with convulsions. 

Ethereal Sulphates. — The important substances of this group are 
phenol, cresol, pyrocatechin, indol, and skatol. These bodies, as a 
rule, appear in the urine as the sodium or potassium salts of the 
ethereal sulphates. Indol and skatol are not eliminated as indol- 
or skatol-sulphuric acid, but undergo preliminary oxidation to in- 
doxyl and skatoxyl, appearing in the urine as the sodium or potassium 
salts of indoxyl-sulphuric acid (indican) and of skatoxyl-sulphuric 
acid. The ethereal sulphates are products of decomposition, and the 
amount normally excreted in the urine varies with the extent of putre- 
faction in the intestines, as well as according to the character of the 
food. Their proportion to that of the total sulphates of the urine 
is about one to ten. They are increased whenever putrefactive 
processes exist in any part of the body, such as putrid pus cavities and 
gangrenous tissues ; their amount is proportional to the severity of the 
putrefaction, being increased by the retention and diminished by the 
discharge of putrid matter. They are also increased after the use of 
certain drugs, such as carbolic acid and lysol, internally or externally. 

Phenol and cresol may be detected in the urine by adding strong- 
nitric acid and boiling, when an obor of bitter almonds will develop. 
After cooling, add bromine water; a yellow crystalline precipitate of 
tribromphenol appears upon standing. If a portion of the original 
test is rendered strongly alkaline by the addition of sodium hydroxide, 
an orange-red color is observed, due to the formation of sodium 
nitro-phenol. 

Coloring Matters. — Normal urine contains a number of coloring 



NORMAL CONSTITUENTS. 30 

matters as well as so-called chromogens, which, though colorless, readily 
become colored by oxidation. 

Urochrome is the yellow pigment which gives the normal amber 
color to the urine. It can be isolated as a brown, easily soluble powder, 
giving yellow solutions in water and alcohol. It is precipitated by 
different acids. 

Hcematoporphyrin is present in minute quantities in normal urine; 
it is an iron-free derivative of haemoglobin. It is increased in croupous 
pneumonia, pulmonary tuberculosis, pericarditis, exophthalmic goitre, 
Addison's disease, rheumatism and gout, lead-poisoning, and par- 
oxysmal haemoglobinuria, also after prolonged use of sulphonal and 
trional or in acute poisoning with these drugs. Urine containing 
larger quantities of haematoporphyrin has a dark wine-red, bluish- 
red, or even almost black color. 

Uroerythrin, the pigment that gives the pink color to urate deposits, 
is of no practical importance, while urohcematin is a derivative of 
haemoglobin and is probably derived from the disintegration of 
haemoglobin. 

Urobilin is not usually present in freshly voided urine, but a small 
quantity soon forms on standing from oxidation of urobilinogen, a 
chromogen, which is present in fresh urine. It is formed by the re- 
ducing action of putrefactive intestinal bacteria on the bile pigments, 
and is greatly increased in diseases accompanied by marked destruc- 
tion of red blood corpuscles or extravasation of blood into the tissues, 
such as pernicious anaemia, purpura, scurvy, cerebral apoplexy, and 
hemorrhagic infarcts. It is also increased in many febrile diseases, 
septic conditions, acute articular rheumatism, pneumonia, malaria, 
scarlet fever, diseases of the liver and bile ducts, as well as in lead 
colic, and has been found after administration of antipyrin and 
antifebrin. 

Detection of urobilin: Fill a test tube three-quarters with urine 
and add one drop of hydrochloric acid and 5 c.c. of amyl alcohol. 
Shake gently a few times, allow to stand a few minutes, pipette off 
layer of alcohol into another test tube, dilute with two volumes ninety- 
five per cent, ethyl alcohol, add one drop of ammonia water to neu- 
tralize the acid added at first, and 1 c.c. five per cent, alcoholic solution 
of zinc chloride. Filter off any precipitate of zinc hydroxide and ob- 
serve a green fluorescence of the filtrate in the presence of urobilin, 
destroyed by the slightest trace of acid. 

Of other organic constituents of normal urine, oxalic acid may be 
mentioned. It is present in very small quantities, but is increased 



40 URINARY ANALYSIS AND DIAGNOSIS. 

whenever there is an interference with oxidation in the body, being 
found in diseases of the heart, lungs, and liver, as well as in diabetes. 
It usually occurs in the form of calcium oxalate, a salt which crystal- 
lizes and is deposited in the urinary sediment when it is present in 
excess. The significance of oxaluria is discussed in the chapter on 
crystalline and amorphous sediments. Different volatile fatty acids 
are also present in minute amounts; the most important of these are 
formic, acetic, butyric and propionic acids. They are increased in 
some febrile conditions, and such an increase is known as lipaciduria. 
Ferments, such as pepsin and lipase are frequently present, but in traces 
only, likewise aromatic oxy acids. 

B. INOKGANIC. 

The chief inorganic constituents of urine are the chlorides, phos- 
phates, and sulphates which occur in combination with potassium, 
sodium, ammonium, calcium, and magnesium. In addition to these 
there are small amounts of carbonates and minute quantities of iron, 
fluorin, silicic acid, and free gases, including nitrogen, carbonic acid, 
and traces of oxygen. The total amount of inorganic substances 
excreted in twenty-four hours is between 12 and 27 gm. 

Chlorides. — Next to urea, the chlorides are the chief solid con- 
stituents of the urine. The most important and most abundant of the 
chlorides is chloride of sodium, but small quantities of chloride of 
potassium and ammonium are also present. The amount of the 
chlorides voided varies considerably with the diet, being derived from 
the food, and they are most abundant when a large amount of salty 
food is ingested. The average quantity voided is between 10 and 16 
gm. (2J to 4 drachms) in twenty-four hours; a milk diet considerably 
reduces this amount, while an abundance of salty food may increase 
it to 30 or 40 gm. In starvation the chlorides almost entirely disappear 
from the urine. When starvation is followed by feeding, they do not 
appear again until the system has reabsorbed the amount voided when 
starvation began. 

The excretion of chlorides is diminished in all febrile conditions, 
especially in those in which a serous exudate is formed. In pneumonia 
their excretion is greatly reduced during the florid stages of the disease, 
but rapidly increases when the exudate becomes absorbed and convales- 
cence sets in. The chlorides are also diminished in diarrhoea and may 
sink to a minimum in severe gastric disorders, such as ulcer and cancer, 
in which very little food is taken. In chronic diseases accompanied by 
oedema, such as chronic nephritis, the chlorides are considerably dimin- 



NORMAL CONSTITUENTS. 41 

ished, and if the fluid is absorbed they gradually rise. In nephritis the 
chloride excretion usually follows the same course as the urea excretion. 
The chlorides are increased during active exercise and, as a rule, in dia- 
betes, both mellitus and insipidus. 

The chlorides may be detected by treating the urine with nitric acid 
and adding a solution of nitrate of silver; a cheesy precipitate, soluble in 
ammonia, shows the presence of chlorides. A test of the approximate 
amount of chlorides present may be made with this method, as follows: 
To a small amount of urine in a test tube add a few drops of nitric acid, 
and to this one or two drops of a nitrate-of-silver solution, one part to 
eight. If a white, flaky precipitate is formed, which quickly sinks to 
the bottom of the test tube without diffusing through the urine, the 
chlorides are present in normal amount (from one-half to one per cent) . 
If a simple cloudiness appears, readily diffusing through the urine 
without the appearance of flakes, the chlorides are diminished to one- 
tenth per cent; and if no precipitate whatever is formed, they are en- 
tirely absent. If more than a trace of albumin is present it should be 
removed by heat before applying this test, as albuminate of silver 
forms and interferes with the reaction. 

For quantitative estimation Mohr's titration method with silver ni- 
trate can be used. The solutions required are: 

1. Standard nitrate-of-silver solution: Dissolve 29.075 gm. of fused 
nitrate of silver in 1,000 c.c. of distilled water; 1 c.c. of this solution is 
equal to 0.01 of sodium chloride. 

2. A saturated watery solution of neutral potassium chromate, 
made by dissolving one part of the salt in five parts of water. 

Take 10 c.c. of urine; dilute with 50 c.c. of distilled water; add 8 
to 10 drops of potassium-chromate solution; to this mixture add the 
standard silver solution drop by drop from a burette. The chlorine 
combines with the silver to form a silver chloride in the form of a white 
precipitate. When all the chlorine is precipitated, silver chromate, red 
in color, forms, and the silver-nitrate solution must be added until a 
pink tinge appears. The number of cubic centimetres of silver solu- 
tion used, multiplied by 0.01, will give the amount of chlorides in 10 c.c. 
of urine, from which the total for twenty- four hours is calculated. 

Phosphates.— Phosphates are found in the urine as salts of sodium, 
potassium, calcium, and magnesium. The combinations of phos- 
phoric acid with sodium and potassium constitute the alkaline phos- 
phates; the combinations with calcium and magnesium the earthy 
phosphates. The phosphoric-acid excretion is usually expressed in 
terms of P 2 5 ; that is, phosphoric-acid anhydride; and the amount 
voided in twenty-four hours varies from 2.3 to 5 gm., the average being 



42 URINARY ANALYSIS AND DIAGNOSIS. 

3.5 gm. (less than one drachm). Of this amount about two-thirds is 
in combination with sodium and potassium (sixty per cent of which is 
acid sodium phosphate), and one-third in combination with calcium 
and magnesium. A minute amount is present as glycero-phosphoric 
acid. 

The alkaline phosphates are soluble in water and alkalies, while the 
earthy phosphates are insoluble in water and are held in solution in 
acid urine, but are precipitated in alkaline urine, forming a sediment 
more marked if heat be applied. On heating a faintly acid, amphoteric, 
or alkaline urine, a precipitate forms, which may be mistaken for al- 
bumin; from this it may be easily distinguished by the addition of two 
or three drops of an acid, such as acetic or nitric, which quickly dis- 
solves the earthy phosphates. If the magnesium phosphate be acted 
upon by ammonia, the ammonio-magnesium phosphate — so-called 
triple phosphate — is formed. 

The phosphates in the urine are derived partly from the food, partly 
from the decomposition of organic substances containing phosphorus, 
such as nuclein and lecithin; they are more abundant after an animal, 
less abundant after a vegetable, diet. A continued increase in the 
total amount of phosphates in the urine is spoken of as phosphaturia. 
A diagnosis of this condition is usually based upon the presence in the 
urine of a dense deposit of phosphates; analyses of many of these 
cases, however, do not show an increased amount of phosphoric acid, 
but merely a diminished acidity of the urine, and the diagnosis of 
phosphaturia should not be applied to them. 

The amount of phosphates excreted in the urine is increased in dia- 
betes mellitus, in diseases of the bone, such as osteomalacia and rachitis, 
in diseases of the nerve centres, and in destructive pulmonary diseases, 
such as tuberculosis. It is diminished in severe diseases of the kid- 
ney, in a variety of acute infections such as pneumonia at the height of 
the disease, in different chronic diseases, and during pregnancy, prob- 
ably due to the formation of the fcetal bones, sometimes also in gout. 

A condition known as phosphatic diabetes, and considered to be an 
independent disease of metabolism has been described. In this con- 
dition the symptoms are similar to those in diabetes mellitus with a 
polyuria and a continuous large increase of phosphates in the urine as 
high as 10 gm. or more in twenty-four hours, but without a glycosuria. 
In true diabetes mellitus the phosphates may be increased at one time 
and diminished at another, there frequently being an inverse ratio 
between the excretion of sugar and phosphates. 

The earthy phosphates may be detected by rendering the urine 
strongly alkaline with ammonia or caustic potash and gently heating, 



NORMAL CONSTITUENTS. 43 

which causes their precipitation in the form of a whitish cloud of 
feathery flakes that settles to the bottom of the test tube. The pre- 
cipitate is dissolved on the addition of acetic acid. To detect the alka- 
line phosphates, remove the earthy phosphates by precipitation and 
filter. To a given quantity of the filtrate add one-third the quantity 
of magnesian fluid (1 part each of magnesium sulphate and ammo- 
nium chloride, 8 parts of distilled water, and 1 part of liquor ammonia?). 
The alkaline phosphates are precipitated in the form of a snow- 
white deposit. If the entire fluid presents a milk-like, cloudy ap- 
pearance, the alkaline phosphates are present in normal amount; if 
it is denser and more cream-like, there is an increase; but if the fluid 
is only slightly cloudy or remains transparent, the phosphates are 
diminished. 

To estimate the amount of total phosphoric acid in the urine, the 
best method is that of titration with uranium nitrate or acetate. It 
is based upon the fact that a solution of a phosphate acidulated with 
acetic acid, when treated with a uranium nitrate or acetate solution 
gives a yellowish-white precipitate of uranium phosphate, and when a 
soluble salt of uranium is added to a solution of potassium f errocyanide, 
a reddish-brown precipitate develops. The solutions required are: 

1. A standard solution of uranium nitrate or acetate, consisting of 
35.5 gm. of the salt to 1,000 c.c. of distilled water; 1 c.c. corresponds 
to 5 mgm. of phosphoric anhydride. 

2. Sodium-acetate solution, 100 gm. of sodium acetate being dis- 
solved in 900 c.c. of water, and to this mixture 100 c.c. of a thirty per 
cent solution of acetic acid being added. 

3. A saturated solution of potassium f errocyanide, to be used as an 
indicator. 

To 50 c.c. of the urine in a glass beaker add 5 c.c. of the sodium- 
acetate solution. Heat over a water bath and add the uranium solu- 
tion drop by drop, as long as a precipitate forms or until a drop of the 
mixture, placed upon a porcelain plate, gives a distinct brown color 
with a drop of potassium f errocyanide. The number of cubic centi- 
metres of the uranium solution is then read off and multiplied by 
0.005 (5 mgm.), which gives the amount of phosphoric acid in 50 c.c. 
of urine; from this the quantity in twenty-four hours is calculated. 
The end reaction, shown by the brown color on the porcelain dish, 
takes place when the uranium solution has precipitated all the phos- 
phoric acid and is present in excess. 

Instead of potassium ferrocyanide as an indicator, cochineal tinc- 
ture may be used. A few drops of it are added to the urine before 
heating, and the standard uranium solution is then added until a faint, 



44 URINARY ANALYSIS AND DIAGNOSIS. 

but distinct and permanent green color appears; this color begins to 
appear as soon as all the phosphoric acid has been precipitated, and 
there is a slight excess of uranium. This indicator has the advantage 
that it may be added directly to the urine before heating. 

To estimate the amount of phosphoric acid in combination with 
calcium and magnesium, that is the earthy phosphates, the following 
method may be used : To 100 c.c. of urine in a beaker add an excess of 
ammonium hydroxide and allow the mixture to stand for from twelve 
to twenty-four hours. The phosphoric acid in combination with 
the alkaline earths, calcium and magnesium, is precipitated as phos- 
phates of these metals under these conditions. Collect the pre- 
cipitate on a filter paper and wash it with dilute ammonia water 
(1 to 3). The filter is then pierced, the precipitate washed down with 
hot water into a beaker, and dissolved while warm with a small amount 
of dilute acetic acid. Bring the volume up to 50 c.c. with water, and 
add 5 c.c. of sodium acetate. Now proceed as in the preceding 
method. The difference between the total amount of phosphoric acid 
and that in combination with the alkaline earths, represents the 
quantity combined with the alkalies, that is the alkaline phosphates. 

Sulphates. — The sulphates occurring in the urine are of three 
kinds: first, the preformed, mineral or inorganic sulphates, which 
occur as compounds of sodium, potassium, calcium, and magnesium, 
the former predominating; second, the neutral sulphates, unoxidized or 
organic sulphur, excreted as a constituent of such bodies as cystine, 
taurine, sulphocyanates, hydrogen sulphide, oxyproteic acid, allo- 
xyproteic acid, and uroferric acid; third, the ethereal sulphates, also 
known as the aromatic or conjugate sulphates, that is sulphuric acid 
in combination with aromatic bodies, such as phenol, indol, skatol, 
cresol, pyrocatechin, and hydrochinon. The first two form about 
ninety per cent, the third about ten per cent of the total sulphuric 
acid. • 

The quantity excreted by the kidneys varies from 1.5 to 3 gm. (23 
to 45 grains) in twenty-four hours. Sulphates are extremely soluble 
and are never met with in the form of deposits, excepting calcium 
sulphate. They are derived partly from the food and partly from 
the decomposition of proteins in the tissues. The total quantity bears 
a fairly constant relation to total nitrogen, being one to five. 

An increased excretion of sulphates takes place after a meat diet 
and as a result of active exercise; this is also the case in acute fevers 
with an increased excretion of urea. After taking sulphuric acid or 
sulphates and after the inhalation of oxygen, they are likewise in- 
creased. Sulphates are diminished after a strictly vegetable diet, in 



NORMAL CONSTITUENTS. 45 

nephritis, in convalescence from acute diseases, and in all conditions 
associated with diminished metabolism. 

Sulphates may be detected by adding to a given quantity of urine 
in a test tube one-third as much of an acidulated solution of barium 
chloride (4 parts of barium chloride, 16 parts of distilled water, 1 part 
of concentrated hydrochloric acid). An opaque, milky cloudiness will 
appear when the amount of the sulphates is normal. If the opacity is 
intense and the mixture has the appearance of cream, the sulphates are 
increased; but if there is only a slight cloudiness, they are diminished. 

To estimate the amount of total sulphates the volumetric method 
may be employed. The following solutions are required: 

1. A standard solution of barium chloride, made by dissolving 
30.54 gm. of crystallized barium chloride in 1,000 c.c. of distilled 
water; 1 c.c. of this solution corresponds to 0.01 gm. of sulphuric-acid 
anhydride (S0 3 ). 

2. A solution of potassium sulphate, containing 21.778 gm. of the 
salt in 1,000 c.c. of water. 

3. Pure hydrochloric acid. 

One hundred cubic centimetres of urine are rendered acid by the 
addition of 5 to 10 c.c. of hydrochloric acid and heated to boiling in a 
flask. The barium-chloride solution is allowed to drop into the mix- 
ture as long as any precipitate occurs, the mixture being heated before 
each addition of the barium solution. After adding 5 to 8 c.c. of the 
solution, allow the precipitate to settle; filter a small portion of the 
mixture and add a few drops of the standard solution. If any precipi- 
tate occurs, return the whole to the flask, add more barium solution, 
and test as before, until no more precipitate is formed on the addition 
of barium chloride. An excess of the latter should be avoided. 

If only a trace of excess is present, a drop of the clear fluid re- 
moved from the flask gives a cloudiness with a drop of potassium-sul- 
phate solution placed on a glass plate over a black background. If 
more than a cloudiness appears, too much barium chloride has been 
added, and the test must be repeated. From the amount of barium 
chloride used, the percentage of sulphuric acid in the urine is calcu- 
lated, 1 c.c. of barium-chloride solution corresponding to 0.01 gm. of 
S0 3 . 

Carbonates. — In urine of an alkaline reaction minute quantities 
of carbonate and bicarbonate of ammonium, calcium, sodium, and 
magnesium are present. As a result of alkaline decomposition of 
the urine, ammonium carbonate may be found in large quantities. 
The carbonates are derived from the food, especially from vegetable 
acids, and may be considerably increased after drinking alkaline 



46 URINARY ANALYSIS AND DIAGNOSIS. 

mineral waters. An excess of carbonates renders the urine turbid 
when passed, or it becomes so upon standing, and upon sedimenta- 
tion the precipitate is that of calcium carbonate, usually associated 
with phosphates. 

The presence of carbonates in the urine is detected by the evolution 
of gas, upon the addition of a few drops of an acid, such as acetic or 
nitric. 

Other inorganic constituents, such as iron, silicic acid, fluorin, 
and hydrogen dioxide, occur in normal urine in traces only, and are of 
no clinical importance. 

Centkifugal Analysis. 

Centrifugal Analysis. — The method of centrifugal analysis for the 
ready approximate determination of bulk percentages of chlorides, 
phosphates, and sulphates, as well as of albumin was introduced by 
Purdy. While by no means accurate, this method is a convenient 
one and has the advantage over other methods for quantitative esti- 
mation of yielding quick results, which are sufficiently accurate for 
clinical work. From the bulk percentages Purdy has determined 
weight percentages. 

Purdy advises the use of an electrical centrifuge possessing a radius 
of arm and tube of 6f inches, accurately graduated percentage 
tubes, with a capacity of 15 c.c. each, and a gauge to regulate the speed. 
He uses the double arm of the motor, carrying four tubes, so that he 
can estimate the bulk percentages of chlorides, phosphates and sul- 
phates, and if necessary also of albumin at the same time. An 
electrical centrifuge is, however, not essential, as a well-made, single 
or double speed hand centrifuge gives practically the same results, 
provided that a uniform speed is maintained. This speed should be 
1,200 or 1,500 revolutions per minute for three minutes, which is ob- 
tained by rotating the handle 50 to 60 times per minute. 

Estimation of Chlorides. — Fill the percentage tubes to the 10 c.c. 
mark with fresh urine; add 1 c.c. (15 to 20 drops) of strong nitric acid 
to prevent precipitation of phosphates, and fill tube to the 15 c.c. 
mark with a silver nitrate solution (1 part to 8 of water). The un- 
graduated tube may be filled with water or urine, if no other tests are 
to be made. Close the tube, mix the contents thoroughly, and allow 
to stand for two or three minutes to secure complete precipitation; 
now centrifugalize for three minutes, at the rate of 1,500 revolutions 
per minute, after which the bulk percentage of silver chloride is read 
off on the scale of the tube. The normal bulk percentage of silver 
chloride ranges from five to eight per cent. 



NORMAL CONSTITUENTS. 47 

From the bulk percentage of silver chloride the percentage by 
weight both of sodium chloride and of chlorine may be calculated. 
Each one-tenth of a cubic centimetre of the precipitate, that is one 
per cent by bulk is equivalent to 0.13 per cent by weight of sodium 
chloride and 0.08 per cent of chlorine. If, for instance, the precipitate 
is five-tenths of a cubic centimetre, that is five per cent by bulk, the 
weight percentage of sodium chloride is 0.65, that is 6.5 gm. per litre 
of urine; if eight per cent by bulk, it is 1.04 or 10.4 gm. per litre; 
and if ten per cent by bulk, it is 1.3 or 13.0 gm. per litre. 

Estimation of Phosphates. — Fill the percentage tube to the 10 c.c. 
mark with urine; add 2 c.c. of 50 per cent acetic acid and 3 c.c. of a 
five per cent uranium-nitrate solution. Close the tube, mix the con- 
tents thoroughly and allow to stand for a few minutes; now centrifu- 
galize for three minutes at the rate of 1,500 revolutions per minute. 
The normal bulk percentage of uranyl phosphate is eight to ten per 
cent. According to Purdy the first one-tenth of a cubic centimetre of 
the precipitate, that is one per cent by bulk of uranyl phosphate, is 
equivalent to 0.04 gm. of phosphoric acid by weight in each 100 c.c. 
of urine. Each succeeding percentage by bulk increases by 0.01. 
For instance, five per cent by bulk of uranyl phosphate equals 0.08 
gm. of phosphoric acid (0.04 plus 0.04) in each 100 c.c, or 0.8 gm. 
per litre of urine; ten per cent by bulk equals 0.13, or 1.3 gm. per 
litre; fourteen per cent by bulk, 0.17 or 1.7 gm. per litre. 

Estimation of Sulphates. — Fill the percentage tube to the 10 c.c. 
mark with urine and add 5 c.c. of barium chloride solution, composed 
of 4 parts of barium chloride, 1 part of concentrated hydrochloric 
acid, and 16 parts of distilled water. Close the tube, mix the con- 
tents thoroughly, and allow to stand for a few minutes; centrifugalize 
for three minutes at the rate of 1,500 revolutions per minute. The 
normal bulk percentage of barium sulphate is about 0.8 per cent. 
Each one-tenth of a cubic centimetre of the precipitate, that is one 
per cent by bulk, is equivalent approximately to 0.25 gm. of sul- 
phuric acid by weight in 100 c.c. of urine. For instance, one-half per 
cent by bulk of barium sulphate equals 0.13 gm. of sulphuric acid by 
weight in 100 c.c. of urine, or 1.3 gm. per litre; one per cent by 
bulk equals 0.25 or 2.5 gm. per litre; one and one-quarter per cent 
0.31 or 3.1 gm. per litre; and 2 per cent, 0.49 or 4.9 gm. per litre. 



CHAPTER V. 

PROTEINS. 

The term proteins or albuminous substances includes a group of 
substances related to each other though differing in constitution and 
properties. The following proteins may be found in the urine: serum- 
albumin, serum-globulin, nucleo-albumin, albumoses and peptone, 
haemoglobin, fibrin, and rarely histon and nucleo-histon, which latter 
are derivatives of the cell nuclei. 

The chief clinical interest centres in serum-albumin, which is fre- 
quently combined with serum-globulin, and by the term albuminuria 
the presence Of these bodies in the urine, without regard to the possi- 
bility of the presence of other proteins, is usually meant. 

Albuminuria. — The presence of albumin in any appreciable 
amount must always be regarded as a pathological phenomenon, al- 
though minute quantities, which escape detection by the ordinary 
clinical tests, are present in some normal urines. The detection of 
albumin in the urine does not necessarily signify the presence of a renal 
trouble, but it may be due to a variety of causes. Even a com- 
paratively large amount may exist without any kidney lesion whatever, 
and it is a grave mistake to conclude that a nephritis must exist be- 
cause albumin has been found. Although in the larger number of 
cases in which albumin is found a nephritis is present, a microscopical 
examination must invariably be made to determine, if possible, the 
exact source of the albumin; and only if pus corpuscles and kidney 
epithelia, with or without the presence of casts, are found, a diagnosis 
of a nephritis is justified. 

On the other hand, a nephritis may exist and yet albumin be found 
in such minute quantities as occasionally to escape detection alto- 
gether. This is sometimes the case in cirrhosis of the kidney, where a 
large amount of albumin is rarely seen, and it may be entirely absent 
for a few hours. In such cases the urine of the entire twenty-four 
hours should be tested before concluding as to the presence of albumin. 

In all cases where pus corpuscles in moderate numbers are found in 
the urine, albumin may always be detected, if careful tests are made, 
though there may be no more than a faint trace. It can thus easily be 
seen that in such widely different lesions as pyelitis, cystitis, pros- 

48 



PROTEINS. 49 

tatitis, urethritis, and vaginitis, it might be present in the urine, and a 
microscopical examination will be necessary to determine its origin. 
In hemorrhage from any portion of the genito-urinary tract, a con- 
siderable amount of albumin is usually found. The rare cases of 
chyluria, in which the kidney may be perfectly intact, are always asso- 
ciated with the presence of a large amount of albumin. These cases 
of extrarenal albuminuria are known as pseudo- or accidental albu- 
minuria, to differentiate them from renal or true albuminuria. 

Disturbances of circulation, due to a variety of causes, may bring 
about the presence of albumin without any structural changes in 
the kidney. Such cases are often roughly termed functional albu- 
minurias. It is not always easy to trace the cause of such albu- 
minurias, though they may be due to prolonged muscular exercise, to 
cold baths, mental shock, to lesions of the nervous system, or to or- 
ganic heart lesions. After eating a heavy protein meal a temporary 
albuminuria, known as alimentary albuminuria may appear. Albu- 
minuria of pregnancy, due to the pressure of the pregnant uterus, is 
very common, and in many of these cases an organic lesion of the 
kidney will develop. 

Another type of functional albuminuria, known as albuminuria of 
adolescence occurs in young neurotic individuals. This as well as 
other forms may be cyclic, that is the albumin recurs periodically 
at certain times of the day, and is absent at other times. Orthostatic 
or postural albuminuria occurs only when the patient is in an erect 
posture, and disappears when he lies down. 

Changes in the composition of the blood with a broken-down con- 
stitution, as seen in anaemia, tuberculosis, malaria, leukaemia, pyaemia, 
etc., when no lesions of the kidney can be discovered, will cause the 
appearance of albumin; and this may also be the case in any other 
febrile condition. The effect of certain poisons upon the blood, such as 
strychnine, pilocarpine, phosphorus, arsenic, lead, potassium chlorate, 
iodine, alcohol, and toxins, may cause the appearance of albumin in 
the urine. 

Before resorting to chemical tests for the detection of albumin in 
the urine, it is advisable to have the urine as clear as possible, as a 
cloudy sample renders the detection of small quantities of albumin 
difficult. In many cases a simple filtration through a double layer of 
filter paper is sufficient. Where this does not suffice, the urine should 
be centrifugalized and then filtered, if necessary, a number of times. 
If the urine is very cloudy, filtration through a tight plug of fine as- 
bestos filtering fibre may clear it up completely. Treating the urine 
with different agents, such as magnesium oxide or talcum, is not ad- 



50 URINARY ANALYSIS AND DIAGNOSIS. 

visable, as experiments have shown that thereby, not only traces, but 
even considerable quantities of albumin may be removed. 

Detection of Albumin in Urine. — 1. Heat Test with Acetic 
Acid. — The tests for albumin are quite numerous, but one of the most 
reliable is the following : Fill an ordinary test tube about one-fourth or 
one- fifth full of urine and boil thoroughly; then add two or three drops 
of a solution composed of equal parts of glacial acetic acid and water. 
If albumin is present the urine becomes cloudy, the cloudiness being 
the more pronounced the larger the amount of albumin. 

The unboiled urine, as brought for examination, is either trans- 
parent or cloudy. When the urine is boiled the results may be the 
following : 

(a) The urine is transparent, and upon boiling remains unchanged. 
This indicates normal urine. 

(6) The urine is transparent, but after boiling becomes cloudy. 
By adding a few drops of acetic acid it clears up entirely. This shows 
the presence of an increased amount of phosphates. If effervescence 
occurs upon the addition of the acid, either calcium carbonate or 
ammonium carbonate (the latter being always held in solution, and 
never precipitated so as to be found under the microscope) is present. 

(c) The urine is transparent, but after boiling becomes cloudy, 
and the cloudiness remains or becomes more pronounced upon the 
addition of the acid. This indicates the presence of albumin, which, in 
larger quantities, will be thrown down in flakes; when very abun- 
dant, the urine may be converted into a jelly-like mass. The acetic- 
acid test will show the presence of the smallest traces of albumin, 
though these may escape detection if not carefully observed. The 
best plan in such cases is to take a second test tube and pour into 
it unboiled urine; then compare the two test tubes by holding them 
against a dark background. When this is done, the faintest trace of 
albumin can be detected by the slight cloudiness in the test tube 
containing the boiled urine. 

(d) The urine is cloudy, but upon boiling clears up entirely and re- 
mains clear upon the addition of the acid. This indicates an excess 
of urates, especially sodium urate. 

(e) The urine is cloudy, the cloudiness disappears upon warming, 
but reappears and becomes more pronounced upon boiling and the 
addition of the acid. This shows an excess of urates, in addition to 
the presence of albumin. 

(/) The urine is cloudy, and remains unchanged by boiling and by 
the addition of acetic acid. This proves the presence of micro-organ- 
isms, such as micrococci and bacilli. 



PROTEINS. 51 

As nucleo-albuniin and mucin are also precipitated by this test, 
Purdy recommends the following method for performing it: Have on 
hand a saturated aqueous solution of sodium chloride. Fill a clean 
test tube about two-thirds full of the previously filtered urine, and 
add to this about one-sixth of its volume of the sodium-chloride 
solution. Next add five to ten drops of acetic acid (fifty per cent) and 
gently heat the upper inch or so of the contents of the test tube for 
about half a minute. If albumin be present, even in the minutest 
traces, it will appear in the upper, boiled portion of the test tube if 
examined in good light. For all practical purposes, however, the 
original test, as given above, is perfectly sufficient and is undoubtedly 
more accurate and sensitive than the nitric-acid test. 

2. Heat Test with Nitric Acid. — A common test for albumin is 
the nitric-acid test, the urine being boiled and a few drops of nitric 
acid added. This test is not as reliable as the preceding, since, if a 
small amount only of albumin be present and the acid added be in ex- 
cess, the albumin may become redissolved. On the other hand, if 
the amount of acid added is small and the phosphates are present in 
excess, a part only of the basic phosphates will be acidified and a 
soluble albuminate will be formed, which remains in solution. 

3. Heller's Test. — Another frequently employed test, known 
simply as "the nitric-acid test," is used as follows: Place a small 
quantity of pure nitric acid in a test tube and allow an equal amount 
of clear, previously filtered urine to trickle from a pipette down the 
side of the inclined tube, so that the urine overlies the acid. If al- 
bumin is present, a distinct, sharp, white zone will appear at the point 
of contact between the acid and the urine, varying in thickness accord- 
ing to the amount of albumin present and according to the rapidity 
with which the urine is dropped into the tube. If only a trace of al- 
bumin be present, a number of minutes may elapse before the zone 
becomes visible. 

This test can also be performed by first pouring the urine into the 
test tube and then allowing the nitric acid to flow down the sides of 
the tube; the acid, being heavier than the urine, will form a separate 
layer below the urine. 

Other substances in the urine may give rise to the formation of a 
nitric-acid ring, and if care is not taken will be mistaken for the zone 
caused by the presence of albumin. Thus in concentrated urines 
urates may form a zone, which, however, does not appear at the point 
of contact between the acid and the urine, but above the point of con- 
tact, and spreads downward; it will disappear on heating. Uric acid 
and urea, if present in large amounts, may be precipitated, but are 



52 URINARY ANALYSIS AND DIAGNOSIS. 

recognized by their crystalline nature. Mucin is also precipitated, but 
is dissolved by the excess of nitric acid at the point of contact. Nucleo- 
albumin and albumoses are likewise precipitated; the former gives a 
fainter ring than albumin, which is above the point of contact, while 
the ring formed by the latter disappears on heating and reappears 
on cooling. 

4. Potassium-ferrocyanide Test. — To 10 c.c. of previously 
filtered urine add five drops of strong acetic acid. If a precipitate 
appears, it is due to nucleo-albumin or mucin and should be .filtered 
off. Then add a few drops of a five to ten per cent potassium-ferro- 
cyanide solution. If a small amount of albumin be present, a faint 
cloudiness at once appears; if a larger amount be present, a flocculent 
precipitate forms at once. Albumose also gives a cloudiness, which, 
however, disappears upon heating. 

5. Spiegler's Test. — This test, as modified by Jolles, consists in 
adding to 4 or 5 c.c. of previously filtered urine 1 c.c. of a thirty per 
cent acetic-acid solution and 4 c.c. of the reagent. The latter is 
composed of 10 gm. mercuric chloride, 20 gm. succinic acid, and 20 
gm. sodium chloride, in 500 c.c. of water. In adding the solutions care 
must be taken that they are not mixed with each other, but layered over 
each other. If albumin be present, a distinct, sharp, white zone, which 
is especially plain on holding the test tube against a dark background, 
at once appears. 

6. Sulpho-salicylic-acid Test. — Add two or three drops of a 
twenty per cent watery solution of sulpho-salicylic acid or a few small 
crystals of the acid to 4 or 5 c.c. of urine in a test tube, and mix 
thoroughly. If small amounts of albumin are present, an opalescent 
cloudiness appears; if larger amounts are present, a pronounced tur- 
bidity or heavy precipitate forms. Albumose is also precipitated by 
this test, but disappears on heating, to reappear on cooling. 

7. Biuret Reaction. — The urine is first treated with a ten per 
cent solution of sodium or potassium hydroxide, and then a ten per 
cent solution of cupric sulphate is added drop by drop. If serum- 
albumin and globulin alone are present, the liquid turns pure violet; 
if albumoses and peptone alone are present, it turns rose; if several 
of the albumins are present together, the urine assumes tints inter- 
mediate between violet and rose. Care should be taken not to add 
too much cupric sulphate, since if the urine contains only small 
amounts of albumin, the color of the copper solution will cover the 
color of the biuret reaction. 

8. Picric-acid Test. — To a given amount of previously filtered 
urine in a test tube add an equal amount of a saturated solution of 



PROTEINS. 



53 



picric acid. If albumin is present, a precipitate forms, varying from a 
light cloud to heavy flakes, according to the amount of albumin. This 
test is delicate, but precipitates other substances besides scrum- 
albumin, which, however, will disappear on heating. 

For performing a number of the above-described tests, but more 
especially Heller's test, a small glass instrument, known as the horis- 
mascope (see Fig. 12), can conveniently be used. The urine to be 
tested is poured into the large tube, and the reagent into the small 
tube. The reagent, being of higher specific gravity than the urine, 
flows down the capillary tube and forms a layer under the urine. 
The slightest opacity at the contact point of the two fluids is easily 
seen against a black background. 



I 




i-0 



Fig. 12. — Horismascope. 



Fig. 13. 



-Esbach's Albuminometer. 



Numerous tests besides these here given have been described and 
have found their adherents. Few authors will agree as to the most 
reliable test for albumin, some preferring the more delicate tests, such 
as Spiegler's and the sulpho-salicylic-acid tests, others Heller's and 
the ferrocyanide tests, still others the heat tests. For all practical 
purposes, the first test given — the heat and acetic-acid test — is perhaps 
the most reliable. If doubt remains as to the presence of albumin, any 
of the other tests described will clear up the question. 

Quantitative Tests for Albumin. — It is of the utmost importance 
to have an approximate idea of the quantity of albumin present in 
any given case, and too many errors are constantly made in this re- 
spect. It is by no means rare to hear of a urine containing twenty-five,, 



54 URINARY ANALYSIS AND DIAGNOSIS. 

forty, or even fifty per cent of albumin. What is thereby meant is, 
of course, per volume; yet such statements are absolutely misleading. 
As a matter of fact, one-tenth of one per cent is a moderate amount of 
albumin, one-twenty-fifth of one per cent being a small amount; 
one-half of one per cent is a large amount, and it is only in com- 
paratively rare cases that one per cent or more is present; more than 
four or five per cent is probably never found. 

The simplest method of estimating the approximate amount of 
albumin is by means of E shack? s albuminometer (see Fig. 13). This 
instrument consists of a graduated glass tube, which is filled with 
urine to the letter U marked upon the tube, and with the test solution 
to the letter R. The latter consists of one part of picric acid to coagu- 
late the albumin, two parts of citric acid to hold the phosphates in 
solution, and distilled water to make one hundred parts. The tube 
is now closed with the rubber stopper supplied with it, and the con- 
tents thoroughly mixed. It is then set aside for twenty-four hours 
to allow the precipitate to settle thoroughly, and the amount of the 
precipitate carefully noted. The tube contains a number of main 
lines of division, each one of which signifies 1 gm. of albumin in 1,000 
gm. — that is, one- tenth of one per cent. Many of the instruments are 
only graduated for seven-tenths of one per cent, and this is sufficient 
for most cases. In those rare cases in which more than that amount 
of albumin is present, the urine must be diluted with one, two, or even 
three parts of water before testing. It must always be borne in mind 
that this method can never be absolutely accurate, since picric acid 
will also precipitate urates, peptone, and vegetable alkaloids; but it 
undoubtedly gives an approximate idea, which is all that is required 
in most cases. 

Creatinin may be an important factor which causes errors in 
Esbach's instrument. An entire precipitate has been found to be a 
compound of potassium picrate with creatinin; it was detected by 
macroscopical appearance and proved by recrystallization from hot 
water. Albumin cannot be recrystallized, and we must guard against 
this possibility of results much too large by Esbach's method. 

Kwilecki's Modification of Esbach's Method. — Esbach's test, al- 
though by no means accurate, is so simple that it is universally used for 
the clinical estimation of the amount of albumin present in the urine, 
the more so since it is sufficiently accurate for ordinary clinical work. 
Its chief drawback is the necessity of waiting twenty-four hours be- 
fore precipitation is complete, and the quantity of albumin can be 
determined. To overcome this, Kwilecki devised a simple modi- 
fication, by means of which small amounts of albumin can be esti- 



PROTEINS. 55 

mated in two minutes, and larger quantities in five or six minutes. The 
method is the following: To the measured amount of urine in Esbach's 
tube add ten drops of a ten per cent solution of ferric chloride before 
the addition of Esbach's reagent. Fill the tube to the letter R with 
the reagent, mix thoroughl}-, and place in a water bath at a tem- 
perature of 72° 0. (162° F.). The precipitation begins almost imme- 
diately and is complete at the end of a few minutes, when the result 
can be read off. 

Tsuchiya's Method. — This is another modification of Esbach's 
method, which is more accurate than the latter. The reagent consists 
of a solution composed of 1.5 gm. of crystalline phosphotungstic acid, 
5 c.c. of concentrated hydrochloric acid, and 93.5 c.c. of ninety-five 
per cent alcohol. The reagent is used with the Esbach tube in the 
same manner as the original test, and twenty-four hours are required 
for complete precipitation. This method gives practically no pre- 
cipitate with normal urine, as is sometimes the case with Esbach's re- 
agent, and the albuminous precipitate settles more regularly and uni- 
formly. With small amounts of albumin this method is decidedly 
preferable to Esbach's. 

Purdy's Centrifugal Method. — The centrifugal method, although 
hardly more exact than Esbach's method, is a very convenient one 
for a rough estimation of the amount of albumin, and is performed 
in a short space of time. Purdy advises the use of an electric cen- 
trifuge, the radius of which, with tubes extended, is exactly 6f 
inches. A good single- or double-speed hand centrifuge, however, gives 
practically the same results, provided that a uniform speed is main- 
tained. The method is performed as follows: Fill the graduated or 
percentage tube to the 10 c.c. mark with urine; add 3 c.c. of a ten 
per cent potassium ferrocyanide solution, and 2 c.c. of a fifty per 
cent acetic acid solution, after which the contents of the tube should be 
thoroughly mixed. Allow the tube to stand for ten minutes, to insure 
the entire precipitation of the albumin. Now centrifugalize for three 
minutes at a uniform speed of 1,200 or 1,500 revolutions per minute, 
and read off the bulk percentage. Each j\ c.c. of the precipitate, 
that is, each division of the tube, represents one per cent of albumin 
by measure, but not by weight. 

According to Purdy, one per cent by bulk represents 0.021 per 
cent of albumin by weight. Purdy's table up to ten per cent is the 
following: J per cent by the centrifuge represents 0.005 per cent by 
weight of dry albumin; J per cent, 0.01; f, 0.016; 1, 0.021; li, 0.026; 
1|, 0.031; If, 0.036: 2, 0.042; 2|, 0.047; 2i, 0.052; 2f , 0.057; 3 per cent, 
0.063; 3|, 0.073; 4, 0.083; 4J, 0.094; 5, 0.104; 5J, 0.111; 6, 0.125; 6i, 



56 URINARY ANALYSIS AND DIAGNOSIS. 

0.135; 7, 0.146; 7§, 0.156; 8, 0.167; 8 J, 0.177; 9, 0.187; 9§, 0.198; and 
10 per cent, 0.208. 

If the amount of albumin is excessive, dilute the urine with water 
till the volume of albumin falls below ten per cent; multiply the result 
by the number of dilutions employed. 

An approximate estimation of the amount of albumin can be ob- 
tained from the amount of precipitate in the bottom of the test tube 
after using the heat and acetic-acid test. A mere clouding is a faint 
trace, trace, or more than trace, according to the degree of the cloud- 
ing; a small but perceptible precipitate is one-fortieth to one-thirtieth 
per cent; if the precipitate forms about one-twentieth of the column 
of urine, the amount of albumin is one-twentieth per cent; if it forms 
about one-tenth of the urine column, one-tenth per cent; one-quarter 
of the urine column, one-fifth to one-fourth per cent; and one-half of 
the urine column, two-fifths to one-half per cent of albumin. 

The most exact method for the determination of the amount of 
albumin is the gravimetric method, which consists in coagulating the 
albumin either by heating or by means of chemical agents, filtering out 
the albumin, collecting, drying, and weighing. It is too elaborate for 
clinical work. 



Removal of Albumin from Urine. — In a number of the general 
quantitative tests, it is advisable to remove the albumin if more than a 
trace is present. The simplest manner of doing this is to acidify the 
urine with acetic acid, boil until a flocculent precipitate forms and fil- 
ter. The filtrate is usually clear and contains no albumin, but does 
contain albumoses. Hofmeister therefore recommends the follow- 
ing method: To a small amount of urine add 10 c.c. of a forty per cent 
sodium acetate solution and the same amount of a ten per cent ferric 
chloride solution, when a bright red color will appear. The urine is 
now rendered neutral or faintly acid and boiled. The albumin sepa- 
rates out with the basic ferric acetate and is filtered off. This method 
can not be used if sugar is present, in which case the urine is simply 
treated as first stated. 



Besides serum-albumin, the urine may contain a number of similar 
but less important substances, among which may be mentioned 
globulin, albumose, peptone, mucin, and fibrin. 

Globulin. — Globulin is almost always associated with serum- 
albumin in every albuminous urine, and its clinical significance is 
nearly identical with the latter. It is, however, more abundant than 



PROTEINS. 



07 



serum-albumin in many cases of acute nephritis and in chronic neph- 
ritis with waxy degeneration of the kidney, also in some cases of 
pneumonia. 

Globulin can be detected by the method of Pohl in the following 
manner: Render the urine neutral or even faintly alkaline by the ad- 
dition of ammonium hydroxide, and filter after standing one or two 
hours ; then add an equal volume of a saturated solution of ammonium 
sulphate. If globulin is present, a white, flocculent precipitate forms 
immediately. 

Another simple method depends upon its insolubility in diluted 
urine. Dilute a certain amount of previously filtered urine with ten 
times the amount of distilled water, and a flocculent precipitate ap- 
pears; this is hastened by the addition of one or two drops of dilute 
acetic or boric acid. Or, fill a test tube wdth water, and allow a few 
drops of the albuminous urine to fall into it. If globulin is present 
in any quantity, each drop of urine as it falls is followed by a milky 
streak, and after a number of drops have been added the water as- 
sumes a milky opalescence throughout. 

Albumoses and Peptones. — The term albumoses or proteoses in- 
cludes a number of albuminous bodies w 7 hich are intermediate prod- 
ucts between albumin and peptone, the end-product of digested albu- 
min. They are formed in the body by the action of the gastric and 
pancreatic juices. They are not coagulated by heat, but are pre- 
cipitated by acids, the precipitate thus formed being redissolved by 
heat. The albumoses are divided into primary and secondary; the 
primary are proto-albumose and hemi- or hetero-albumose; the sec- 
ondary are deutero-albumoses, which so closely resemble peptone in 
its reactions that they cannot always be differentiated from the 
latter. 

The clinical significance of the albumoses is not yet positively 
known. They have been found in urine in a number of different con- 
ditions, such as ulceration of the intestines, tertiary syphilis, hemi- 
plegia, cancer, double pneumonia, scarlet fever, diphtheria, muscular 
atrophy, and abscesses. 

Albumoses are detected by their solubilities and reactions. Proto- 
and deutero-albumose are soluble in hot and cold water, while hetero- 
albumose is insoluble in water; all three are soluble in ten per cent 
solutions of sodium chloride. The primary albumoses are precipitated 
by strong solutions of sodium chloride and magnesium sulphate; also 
by saturated solutions of ammonium sulphate and by cold nitric acid. 
Secondary albumose is not precipitated by strong solutions of sodium 
chloride and magnesium sulphate, but is precipitated by ammonium 



58 URINARY ANALYSIS AND DIAGNOSIS. 

sulphate; with nitric acid it is only precipitated in the presence of an 
excess of sodium chloride. It gives the biuret reaction previously 
described. 

Another albumose, known as Bence-Jones albumose, differs from 
those just described in being coagulated by heat. It is not identical 
with the other albumoses, and its occurrence in urine is rare. It has 
been found in cases of osteomalacia and multiple sarcomata. 

Peptones are the final products of gastric and pancreatic digestion. 
They cannot always be differentiated from albumoses, since both 
have many reactions in common; and the term peptonuria is not 
strictly correct, as albumoses and peptones are usually found together. 
It is a question whether true peptones ever appear in the urine alone. 

These substances are frequently found in many different patho- 
logical conditions. Among these may be mentioned croupous pneu- 
monia, pulmonary tuberculosis, gangrene of the lungs, empyema, cancer 
(especially of the gastro-intestinal tract and the liver), phosphorus- 
poisoning, septicaemia, acute yellow atrophy of the liver, typhoid 
fever, typhus fever, variola, scarlet fever, erysipelas, acute arthritis, 
and suppurative conditions generally. Some authors claim that pep- 
tone is invariably present when pus has formed somewhere in the body, 
and consider it of diagnostic significance in cases in which the clinical 
features are not sufficiently clear for a positive diagnosis. Thus it is 
considered possible to decide as to the presence of a purulent or a 
tubercular meningitis, a purulent or serous arthritis, an empyema or 
serous pleurisy, etc. Peptones have, however, also been found in 
physiological conditions, such as the involution of the pregnant uterus 
— so-called puerperal peptonuria or albumosuria — so that their 
presence does not necessarily signify a diseased condition. 

Peptones are easily soluble in water, do not coagulate by heat, 
and do not precipitate by the addition of most of the reagents used for 
the detection of albumin, such as acetic acid, nitric acid, and potassium 
ferrocyanide. They are precipitated by tannin, pot assio-merc uric 
iodide, picric acid, and phosphotungstic acid. 

They may be detected by the following method: To urine which 
has been slightly acidified by acetic acid, add a saturated solution of 
magnesium or ammonium sulphate, and filter out any precipitate 
formed, which may consist of albumin, globulin, or the albumoses. 
If potassio-mercuric iodide or picric acid is now added and a precipi- 
tate occurs, it consists of peptone. 

Another test is the following: 10 c.c. of urine are acidified with one 
or two drops of hydrochloric acid, the mixture precipitated with a five 
or ten per cent solution of phosphotungstic acid, and heated. The 



PROTEINS. 59 

Bupernatent fluid is poured off and the precipitate dissolved in a few 
cubic centimetres of distilled water to which a small amount of caustic 
soda is added. The solution is heated until it turns yellow. After 
cooling, the addition of a few drops of dilute copper-sulphate solution 
should give a reddish color. 

Mucin (Nucleo-albumin). — Mucin is present in small amount in 
every normal urine, being more abundant in the urine of females, chiefly 
from the vaginal secretion. It is derived from the epithelia of the 
genito-urinary organs, and is considerabty increased in inflammations of 
these organs, more especially those of the bladder, the urethra, pros- 
tate gland, and vagina. When present in large amount, the urine 
appears cloud}' soon after it is voided, and it may form a ropy, jelly- 
like mass, which sinks to the bottom of the vessel. 

To detect its presence in urine, dilute with two or three times the 
amount of water to prevent a precipitation of uric acid upon addition 
of acid. After dilution add an excess of acetic acid. If mucin is pres- 
ent, a more or less pronounced precipitate forms. The precipitate may 
be purified by dissolving in water with a small amount of caustic soda, 
and reprecipitated by acetic acid. To detect it in urine containing 
considerable albumin, precipitate the albumin by boiling, and test 
again with acetic acid. Even small amounts can be readily detected 
with the microscope. 

Fibrin. — Fibrin, the coagulum from blood, lymph, and exudates, is 
found in the urine in greater or less amount in hemorrhages from the 
genito-urinary tract due to various causes, and is also seen in chylous 
urine. In tumors of the bladder, such as papilloma and cancer, where 
hemorrhages occur frequently, it is of common occurrence. It is usu- 
ally present in the form of coagula when the urine is voided, or may be 
precipitated upon standing. 

Fibrin is insoluble in water, alcohol, ether, and in salt solutions, as 
well as in weak acids and alkalies. The addition of weak acid solu- 
tions, such as hydrochloric acid, causes it to swell up into a gelatinous 
mass, which becomes soluble after prolonged boiling. The solutions 
give the general reactions of albumin. It is, however, much easier to 
detect its presence by the microscope. 

Hemoglobin, the chief coloring matter of the blood, is, from a 
chemical standpoint, a chromoprotein. It is discussed under color- 
ing matters. 

Other protein substances, such as histon and nucleo-histon, are occa- 
sionally found in urine, but have no known clinical value. 



CHAPTER VI. 

CARBOHYDRATES. 

A. GRAPE SUGAR. 

Grape sugar, dextrose, or glucose (C 6 Hi 2 6 ) is the only important 
carbohydrate found in urine. There can be little doubt that the urine 
may contain small amounts of sugar under normal conditions, but the 
amount is so minute, usually less than 0.02 per cent, that a positive re- 
action is not obtained with the general methods of detecting dextrose. 

The presence of grape sugar in the urine in appreciable amounts 
temporarily does not necessarily signify the existence of diabetes, any 
more than the presence of albumin signifies the existence of a nephritis. 
After a diet rich in carbohydrates or the ingestion of considerable 
quantities of sweet alcoholic beverages, sugar may appear in the urine 
temporarily; such a condition is spoken of as a physiological or alimen- 
tary glycosuria. 

Pathologically, glycosuria may appear in the urine as a temporary 
condition (transitory glycosuria) in the course of a number of diseases, 
such as Asiatic cholera, intermittent fever, affections of the heart, 
lungs, liver, brain, and spinal cord; alcoholism, gout, and tumors of the 
pancreas. It may occur during pregnancy and in the course of acute 
contagious diseases, such as scarlatina. Furthermore, glycosuria may 
be present in poisoning with certain drugs, such as the alkaloids of 
opium, chloral, chloroform, amyl nitrite, caffeine, curare, and carbonic 
oxide; also after the use of large doses of thyroid extract. 

Whenever sugar is persistently present in appreciable quantity, we 
always have to deal with diabetes mellitus. This disease has been ob- 
served at all ages, and large amounts of sugar may be found; 300 gm. 
in twenty-four hours are not rare, 100 to 200 gm. being the average; 
more than nine or ten per cent are, however, not often excreted. In 
the milder cases no sugar may be present in the morning urine; hence 
it is important to examine the urine at different times of day. In the 
severer cases it is never absent from the urine. The amount of sugar 
does not seem to be a criterion for the severity of the case. A large 
amount of pale or straw-yellow urine, even with a comparatively low 
specific gravity, should always be an indication to examine for sugar, 

60 



CARBOHYDRATES. 61 

even if no other clinical evidences point toward the presence of the 
disease. 

Detection of Sugar in Urine. — The tests for sugar are numerous, 
and in mild cases it may be necessary to resort to two or even three 
different tests before we are positively able to determine the presence 
of sugar. 

1. Moore-Heller Test. — Perhaps the simplest is the Moore- 
Heller test. Although by no means absolutely reliable, it is in many 
cases sufficient to determine the approximate amount of sugar. The 
method is the following : Pour into a test tube two parts of urine and 
one part of a ten per cent caustic-potash solution; boil the upper por- 
tion for two or three minutes. Phosphates, if precipitated in large 
amount, must be filtered off. When sugar is present a change of color 
will take place after boiling, which can be approximately estimated as 
follows: One per cent or less of sugar gives a canary-yellow color, the 
color being somewhat more intense than that of the original unmixed 
urine; between one and two per cent gives a wine-yellow color; between 
two and three per cent, a sherry color; between three and four per cent, 
a rum color; and above four per cent, a dark brown or even black color. 
By the addition of a few drops of nitric acid, the liquid loses its dark 
color and gives out an odor similar to molasses. 

This test is only a tolerably reliable one, but in many cases will 
answer the purpose. The addition of caustic potash to cold urine may 
produce a dark color, which is due to the presence of coloring matters 
of the bile. The white flocculent precipitate, which is almost invari- 
ably seen with this test, is partly due to the phosphates which caustic 
potash may precipitate in cold urine, and partly to mucin. The pres- 
ence of a large amount of mucin may give a similar reaction. 

The most commonly used methods of searching for sugar in the 
urine are the copper tests. They all depend upon the fact that in 
alkaline solutions grape sugar reduces copper salts to oxide. 

2. Trommer's Test. — The oldest of these tests is Trommer's, which 
is used in the following manner : To one or two parts of urine in a test 
tube add one part of caustic potash or soda, adding, drop by drop, a ten 
per cent solution of sulphate of copper, and shake until the mixture 
shows a blue color. Heat the upper part of the mixture, and if sugar is 
present a precipitate of yellow cuprous hydroxide will result, which at 
first shows plainly in the bluish liquid, but gradually spreads over the 
entire fluid, and a red sediment of cuprous oxide is formed. 

If this reaction takes place upon heating, a similar mixture may be 
made and set aside for a number of hours without heating; if sugar is 
present in rather large quantities, a similar precipitate will form. 



62 URINARY ANALYSIS AND DIAGNOSIS. 

Should the reaction by heating be at all doubtful, the second test must 
always be made, since many of the other organic substances, which 
reduce the salts of copper, do so only after heating and boiling. 

This test is open to a number of objections. Albumin, if present in 
large quantities, must first be removed, since it interferes with the re- 
duction of the cupric oxide. A number of substances are, furthermore, 
found in urine which have the property of reducing copper oxide in an 
alkaline solution, among which may be mentioned uric acid, creatinin, 
hippuric acid, and mucin. Again, a small amount of sugar may be 
present in urine and fail to reduce the oxide in the presence of other sub- 
stances, such as urate of ammonium, chloride of ammonium, and other 
ammoniacal compounds. 

3. Fehling's Test. — Fehling's reagent consists of two solutions, 
the copper solution and the alkaline solution. 

(1) Copper solution: Dissolve 34.639 gm. of pure crystallized 
copper sulphate in a sufficient quantity of water under gentle heat, and 
dilute with water to 500 c.c. 

(2) Alkaline solution: Dissolve 173 gm. of chemically pure crystal- 
lized potassium and sodium tartrate and 100 c.c. of caustic-soda 
solution, of a specific gravity of 1.120, in sufficient water to make 
500 c.c. 

These solutions must be kept in separate bottles in a dark place and 
equal volumes mixed before using. Ten cubic centimetres of this solu- 
tion will be reduced completely by 0.05 gm. of sugar. Even if kept 
separately Fehling's solution may decompose, and will then give a pre- 
cipitate on heating, without the addition of urine containing sugar. 

The solution may be used by pouring a small quantity into a test 
tube and diluting it with two or three times the amount of water. The 
mixture should be boiled for a few seconds. If it remains clear after 
boiling, which will usually be the case when the two solutions are kept 
separate and are not too old, add the urine to be tested drop by drop, 
at the same time continuing the boiling. If sugar be present in any 
quantity, the first few drops will usually cause a yellow precipitate; if 
the addition of urine is continued, a yellowish-red sediment will soon 
fall to the bottom of the test tube. Should no such precipitate occur, 
the addition of urine may be continued until an equal volume of urine 
has been added; if then no yellow precipitate appears upon boiling, the 
urine is free from sugar. 

(4) Haines' Test. — This is a modification of Fehling's, for which 
stability is claimed, if well prepared, though kept on hand indefinitely. 
The improved formula consists of 2 gm. (30 grains) of pure copper sul- 
phate and 16 c.c. (one-half ounce) of distilled water; make a perfect 



CARBOHYDRA TES. 63 

solution and add 16 c.c. (one-half ounce) of pure glycerin; mix thor- 
oughly, then add 160 c.c. (5 ounces) of liquor potassae. 

In testing with this solution, pour about 4 c.c. (1 drachm) into a 
test tube and boil it gently. Next add six to eight drops of the urine 
and again boil. If sugar be present, a copious yellow or yellowish-red 
precipitate is formed. If no such precipitate occurs, sugar is not 
present. 

By a modification of this test its delicacy has been increased, and 
the test can be performed by the ring or contact method.* "The 
modification enables a detection with certainty of amounts above 0.03 
per cent of sugar, which is about the upper limit of the so-called nor- 
mal sugar of the urine." 

"Owing to the increase of the specific gravity of the solution, by 
the addition of a larger amount of glycerin, the employment of the con- 
tact test becomes a matter of the greatest simplicity. However, one 
precaution must be taken before this test may be applied. Owing to 
the fact that the phosphates of the urine precipitate when added to the 
alkaline copper solution, these interfering substances must be re- 
moved before the contact test shows in its most perfect manner, other- 
wise a confusing contact ring is observed, which might lead to possible 
errors in interpretation. This removal is accomplished by adding to 
the urine in a test tube 5 or 6 drops of a 5 or 10 per cent solution of 
sodium or potassium hydroxid and allowing the phosphates to settle 
out or centrifuging or filtering if desired to hasten the process." For 
ordinary clinical purposes this removal becomes necessary only if the 
amount of sugar is below 0.1 per cent; if above that amount, the 
reaction with the untreated urine is usually quite distinct. 

The composition of the improved Haines' solution is the following : 
Copper sulphate, 5 gm.; glycerin, 250 c.c; potassium hydroxid, 20 
gm.; distilled water to 1000 c.c. The copper sulphate is dissolved in a 
mixture of the glycerin and an equal amount of water, with the aid 
of gentle heat. The potassium hydroxid should be dissolved in about 
200 c.c. of water and added to the copper solution with constant 
stirring, the whole being made up to volume with distilled water. This 
solution keeps indefinitely. 

While the solution may be used in the same manner as the original 
solution, a much more delicate reaction is obtained as follows: "Heat 
about 5 c.c. of the copper solution to boiling in a test tube, remove from 
the flame and hold at an angle of from 30 to 40 degrees. To this add, 
by means of a medicine dropper, from 10 to 20 drops of the urine freed 
from phosphates in such a manner that a distinct zone of contact is 

* Haines, Pond and Webster: Jour. Am. Med. Assoc, Vol. 74, 1920. 



64 URINARY ANALYSIS AND DIAGNOSIS. 

formed between the copper solution and the urine. The tube is then 
placed in an upright position and the reaction noted. If sugar is 
present in quantities exceeding 0.1 per cent, a brick-red or yellowish 
ring will immediately appear at the junction of the two liquids. If 
the amount of sugar is less than 0.1 per cent, ranging down to 0.03 
per cent, the ring will appear in from a few seconds to slightly less 
than a minute, the smaller quantities showing slower reactions with a 
tendency to a more yellowish color of the ring. In urines containing 
no pathologic sugar, no ring of any kind will be noted at the zone of 
contact." 

5. Benedict's Test. — This is an excellent modification of the old 
copper tests and one of the most delicate tests known. The solution, 
which does not deteriorate upon long standing, has the following com- 
position: Crystallized copper sulphate, 17.3 gm.; sodium or potassium 
citrate, 173 gm. ; crystallized sodium carbonate, 200 gm. (or anhydrous 
100); distilled water, to make 1,000 c.c. The citrate and carbonate 
are dissolved together (with the aid of heat) in about 700 c.c. of 
water. The mixture is then poured (through a filter if necessary) 
into a large beaker. The copper sulphate (which should be dissolved 
separately in about 100 c.c. of water) is then poured slowly into the 
first solution, with constant stirring. The mixture is then cooled and 
diluted to 1 litre, and may be kept indefinitely in uncolored glass- 
or cork-stoppered bottles. 

The method is the following: To about 5 c.c. of the reagent in a 
test tube, add eight or ten drops, but no more, of the urine to be ex- 
amined. The mixture is then boiled vigorously for at least one, but 
preferably two minutes, and allowed to cool spontaneously. In the 
presence of glucose the entire body of the solution will be filled with a 
precipitate, which may be red, yellow, or greenish in tinge. If the 
quantity of glucose be low, that is under 0.3 per cent, the precipitate 
forms only upon cooling. If no sugar be present, the solution either 
remains perfectly clear, or shows a faint turbidity that is blue in 
color, and consists of precipitated urates. 

This reagent is about ten times as sensitive to sugar in urine as is 
Fehling's or Haines' solution, and unlike these latter solutions, is not 
appreciably reduced by creatinin, uric acid, chloroform, or the simple 
aldehydes. Even very small quantities of sugar (0.1 per cent) yield 
precipitates of considerable bulk with this reagent, and the positive 
reaction for glucose is the filling of the entire solution, either before 
or after cooling, with a precipitate, so that the mixture becomes opaque. 
Since bulk, and not color, of the precipitate is made the basis of a 
positive reaction, the test may be carried out as readily in artificial 



CA RBOH YDRA TES. 65 

light as in daylight, even when examining for very small quantities 
of sugar. 

Besides the copper tests, bismuth tests are also used; these depend 
upon the power of grape sugar to reduce the salts of bismuth, giving a 
black precipitate. Of these, two good tests are the following: 

6. Bottger's Test. — Pour one part of urine into a test tube and 
add an equal quantity of a concentrated solution of sodium hydroxide 
or caustic potash, and a small quantity of subnitrate of bismuth. Boil 
for a short time. If sugar is present, a gray or black precipitate ap- 
pears, which will be deposited on the sides of the test tube. If the 
quantity of sugar is small, a grayish color appears. Albumin, if pres- 
ent in large quantities, must first be eliminated by boiling and filtration. 

7. Nylander's Test. — Nylander's reagent is prepared by dissolv- 
ing 4 gm. of Rochelle salt in 100 c.c. of a ten per cent, sodium or potas- 
sium hydroxide, warming the solution and adding 2 gm. of bismuth 
subnitrate. The reagent is then cooled and filtered; it should be kept 
in a dark bottle. The test is carried out as follows: To about 5 c.c. 
of urine in a test tube add one-tenth its volume of the reagent and heat 
for from three to five minutes. If sugar is present, the mixture will 
darken, and upon standing for a few moments a black color will appear, 
which is due to the precipitation of bismuth. As small an amount of 
glucose as 0.08 per cent may be detected by this reaction, but when 
traces only are present the solution will turn brown and not black. 
Reduction of bismuth after the fluid has cooled is not due to bismuth. 
When no sugar is present there may be a white precipitate due to 
phosphates. When more than a trace of albumin is present, this must 
be removed by boiling and filtering before applying the test, since a 
similar change of color is produced with albumin. When an excess 
of urinary coloring matters is present, a partial reaction may occur, 
and the same may occur after different medicinal substances. 

8. Phenylhydrazin Test. — Phenylhydrazin forms with dextrose 
a compound known as phenylglucosazon, which is almost insoluble in 
cold water and separates in hot solutions in a characteristic crystalline 
form. This test is performed as follows: Pour 10 c.c of the urine into a 
test tube and add to it 0.4 gm. of phenylhydrazin hydrochloride and 
0.8 gm. of sodium acetate; immerse the test tube in a water bath and 
boil for one-half to one hour; remove the tube and set it aside to cool. 
At the end of half an hour typical crystals of phenylglucosazon separate 
when sugar is present. These crystals appear under the microscope in 
the form of fine, bright yellow needles, arranged in bundles, sheaves, 
or rosettes. 

These eight tests represent only a fraction of those in use, but 

5 



66 URINARY ANALYSIS AND DIAGNOSIS. 

are the more important. The others offer no advantages over those 
described. 

Quantitative Tests for Sugar. — For a rough quantitative determina- 
tion of sugar in the urine, the Moore-Heller test, previously described, 
can be used. It is, however, not very accurate, and of little value if the 
amount of sugar is below one per cent. Of the other methods em- 
ployed for quantitative estimation, the fermentation tests, Fehling's, 
and Benedict's tests are simple and fairly accurate. The method by 
means of the polariscope is probably the most accurate when the 
amount of sugar exceeds one per cent. It depends upon the fact that 
dextrose rotates polarized light toward the right, and that the degree of 
rotation varies in proportion to the percentage of sugar in the urine. 
The different instruments devised for this purpose are elaborate and 
costly. 

Fehling's Test. — The principle upon which Fehling's solution de- 
pends lies in the fact that, in the reduction of oxide of copper by grape 
sugar, the blue color disappears by the addition of a definite quantity of 
the sugar. As before said, 10 c.c. of the solution correspond to 0.05 gm. 
of sugar. The test may be conducted in the following manner : Dilute 

1 c.c. of Fehling's solution with 4 c.c. of water in a test tube, and, after 
heating, add 0.1 c.c. of the urine to be examined from a graduated 
pipette. Heat must then be reapplied, the precipitate watched, 
another 0.1 c.c. added, and the heat again applied, until, after allowing 
it to stand for a short time, it is found that all the blue color is removed 
from the solution. If, in doing this, 1 c.c. of urine has been added, it 
contains one-half of one per cent of sugar; if more than 1 c.c, it con- 
tains less than one-half per cent, but more than one-fourth per cent; if 

2 c.c. are used, it contains one-fourth per cent; and if 0.5 c.c. is used, 
it contains one per cent of sugar. If the proportion of sugar is large, 
as is usually the case with a high specific gravity, the urine should be 
diluted five to ten times. 

Roberts' Fermentation Test. — This is an excellent and simple 
test, being used as follows : Into each of two bottles, one of four ounces, 
the other of twelve ounces capacity, pour 4 ounces of urine. Add a 
piece of fresh yeast the size of a walnut to the urine in the larger bottle, 
which must be closed with a cork nicked for the escape of gas evolved 
by fermentation. The smaller bottle must be tightly corked, and the 
two bottles placed side by side in a uniform temperature of 68° to 75° 
F. — the average temperature of the room. At the end of twenty-four 
hours fermentation will be completed. The specific gravity of each 
specimen must then be carefully taken by means of the urinometer, 
and the difference of the specific gravity indicates the number of grains 






CARBOHYDRATES. 



67 




Fig. 14. — Einhorn's 
Fermentation SAC- 
CHAROMETER. 



of sugar per fluidounce. For example, if the specific gravity of the 
unfermented urine is 1.035 and that of the fermented urine 1.020, the 
urine contains 15 grains of sugar to the fluidounce, or three per cent. 
This test, although not absolutely accurate, is sufficiently so for 
practical purposes. 

Einhorn's Fermentation Saccharometer. — One of the simplest 
tests, which will be found to answer all purposes, is by means of Ein- 
horn's fermentation saccharometer (see Fig. 14). 
The apparatus is put up in the form of a set, 
consisting of two saccharometers and one gradu- 
ated test tube. The method is the following: 
Take 1 gm. (about 15 grains) of fresh commer- 
cial compressed yeast, and shake thoroughly in 
the graduated test tube with 10 c.c. of the 
urine to be examined. Then pour the mixture 
into the bulb of the saccharometer. By in- 
clining the apparatus the mixture will easily 
flow into the cylinder, thereby forcing out the 
air. Owing to the atmospheric pressure, the 
fluid does not flow back, but remains there. 
Leave the apparatus undisturbed for twenty or 
twenty-four hours in a room of ordinary temperature. 

If the urine contains sugar, the alcoholic fermentation begins in 
about twenty to thirty minutes. The evolved carbonic-acid gas gathers 
on the top of the cylinder, forcing the fluid back into the bulb. On the 
following day the upper part of the cylinder will be found filled with 
carbonic-acid gas. The changed level of the fluid in the cylinder shows 
that the sugar reaction has taken place, and indicates, by the numbers 
upon the cylinder to which it corresponds, the approximate amount of 
sugar present. If the urine contains more than one per cent of sugar, 
it must be diluted with water before being tested; urine of a specific 
gravity of 1.018 to 1.020 may be diluted twice; of 1.021 to 1.028, 
five times; 1.029 to 1.038, ten times. 

In carrying out this test it is always advisable to take, besides the 
urine to be tested, a normal specimen, and make the same fermenta- 
tion test with it. The mixture of the normal urine with yeast will, on 
the following day, have only a small bubble on the top of the cylinder. 
This proves at once the efficacy and purity of the yeast. If, in the 
suspected urine, there is also a small bubble on the top of the cylinder, 
no sugar is present; but if there is a much larger gas volume, we are 
sure that the urine contains sugar. 

Benedict's Quantitative Test. — By modifying his solution for 



68 URINARY ANALYSIS AND DIAGNOSIS. 

qualitative sugar tests, Benedict has been able to apply the reagent 
to a rapid and accurate estimation of sugar in the urine. "Like 
Fehling's quantitative process, the method is based on the fact that 
in alkaline solution a given quantity of glucose reduces a definite 
amount of copper, thus decolorizing a certain amount of the copper 
solution. The copper is, however, precipitated as cuprous sulphocyan- 
ate, a snow-white compound, which is an aid to accurate observation 
of the disappearance of the last trace of blue color. The solution for 
quantitative work, which keeps indefinitely, has the following com- 
position: Pure crystallized copper sulphate, 18 gm.; crystallized sodium 
carbonate, 200 gm. (or anhydrous 100) ; sodium or potassium citrate, 
200 gm.; potassium sulphocyanate, 125 gm.; five per cent potassium 
ferrocyanide solution, 5 c.c; distilled water to make a total vol- 
ume of 1000 c.c. With the aid of heat dissolve the carbonate, cit- 
rate and sulphocyanate in enough water to make about 800 c.c. of the 
mixture, and filter if necessary. Dissolve the copper sulphate sepa- 
rately in about 100 c.c. of water, and pour the solution into the other 
liquid, with constant stirring. Add the ferrocyanide solution, cool and 
dilute to exactly one litre. Of the various constituents, the copper salt- 
only, need be weighed with exactness. Twenty-five cubic centimetres 
of the reagent are reduced by 50 mgm. (0.050 gm.) of glucose." 

The sugar estimation is conducted as follows: " The urine, 10 c.c. of 
which should be diluted with water to 100 c.c. (unless the sugar con- 
tent is believed to be low), is poured into a 50 c.c. burette up to the zero 
mark. Twenty-five cubic centimetres of the reagent are measured 
with a pipette into a porcelain evaporation dish (25-30 cm. in di- 
ameter), 10 to 20 gm. of crystallized sodium carbonate (or one-half the 
weight of the anhydrous salt) are added, together with a small quantity 
of powdered pumice stone or talcum, and the mixture heated to boiling 
over a free flame until the carbonate has entirely dissolved. The di- 
luted urine is now run in from the burette, rather rapidly until a chalk- 
white precipitate forms, and the blue color of the mixture begins to 
lessen perceptibly, after which the solution from the burette must be 
run in a few drops at a time, until the disappearance of the last trace 
of blue color which marks the end-point. The solution must be kept 
vigorously boiling throughout the entire titration. If the mixture 
becomes too concentrated during the process, water may be added from 
time to time to replace the volume lost by evaporation." 

" The calculation of the percentage of sugar in the original sample of 
urine is very simple. The 25 c.c. of copper solution are reduced by 
exactly 50 mgm. of glucose. Therefore the volume run out of the bur- 
ette to effect the reduction contained 50 mgm. of the sugar. When the 



CARBOHYDRATES. 69 

urine is diluted 1 :10, as in the usual titration of diabetic urines, the 
formula for calculating the per cent of the sugar is the following : 

— X 1000 = per cent in original sample, wherein x is the number 

A 

of cubic centimetres of the diluted urine required to reduce 25 c.c. of 
the copper solution." 

"In the use of this method chloroform must not be present during 
the titration. If used as a preservative in the urine it may be removed 
by boiling a sample for a few minutes, and then diluting to the original 
volume." 

Benedict claims great accuracy for this method, it being, as he 
says, probably more exact than any other titration method available 
for sugar work. 

B. OTHER CARBOHYDRATES. 

Fruit sugar, levulose (C 6 Hi 2 06), is rarely found in urine, and may be 
associated with dextrose in diabetes. It has been found in cases of 
melancholia and impotence, but its exact clinical significance is not 
understood. Levulose rotates polarized light to the left, in contradis- 
tinction to dextrose, which rotates it to the right. It reduces salts of 
copper, but more feebly than dextrose. 

Levulose gives a typical reaction, known as Seliwanoffs reaction: 
To 10 c.c. of urine add a small amount of resorcin and 2 c.c. diluted 
hydrochloric acid; mix and heat in a test tube. If levulose is present 
the liquid turns red and precipitates a dark sediment, which is soluble 
in alcohol with a bright red color. 

Milk sugar, lactose (C12H22O11), is sometimes found in the urine of 
nursing women, but is usually present in small amount only, rarely 
more than one per cent. Pavy has found it as late as five months after 
parturition in women in whom an overabundance of milk secretion was 
present, as well as in some women who interrupted the nursing of their 
children. It has no pathological significance, but is important because 
it may be mistaken for dextrose 

Lactose may be detected with Rubner's test: To 10 c.c. of urine add 
3 gm. of lead acetate; filter off the precipitate and heat the filtrate in a 
test tube for a few minutes, until a yellowish-brown color appears; 
now add ammonia and continue heating. If lactose is present, a 
brick-red color appears in the solution and a cherry-red or copper- 
colored precipitate settles at the bottom of the test tube, while the 
supernatent fluid becomes colorless. 

Maltose or isomaltose (C12H22O11) has been found in a number of 
cases of disease of the pancreas in very small amount, usually not more 



70 URINARY ANALYSIS AND DIAGNOSIS. 

than 0.1 to 0.5 per cent. It reduces copper solutions, but not as 
strongly as does glucose. Ten cubic centimetres of Fehling's solution 
are completely reduced by 0.0807 gm. of maltose. 

Cane sugar, saccharose (C12H22O11) is rarely found in urine and is 
of no clinical importance. It may be found after eating large amounts 
of cane sugar, and in the urines of hysterical patients who have added 
it to deceive the physician. Pure saccharose does not reduce Fehling's 
solution . 

Pentoses (C5H10O5) are occasionally found in urine; the more im- 
portant are rhamnose, arabinose and xylose. Different varieties of 
pentosuria have been described: 1 Alimentary pentosuria, which 
is found after the ingestion of pentose- containing food, such as 
apples, plums, cherries and different vegetables, also after drink- 
ing fruit syrups and malt liquors; 2. diabetic pentosuria, pen- 
tose being present in severe forms of diabetes; 3. idiopathic or 
intrinsic pentosuria, the cause of which is unknown. 

The pentoses reduce copper solutions, but the reduction is much 
slower than with other carbohydrates, appearing during the cooling of 
the fluid. Ten cubic centimetres of Fehling's solution are reduced by 
0.0542 gm. of pentose. The fermentation test is negative. With 
Nylander's test they give a gray precipitate. They may be detected 
with BiaVs orcin test. The reagent consists of 500 c.c. of thirty per 
cent hydrochloric acid, 1 gm. of orcin, and twenty-five drops of ten per 
cent ferric chloride solution. Five cubic centimetres of this reagent are 
boiled in a test tube and after removal from the flame the urine is added 
drop by drop, at most 1 c.c. being used; a green color will appear 
almost immediately. 

Glycuronic acid (CeHioO?) does not occur in the urine as such, but 
only in combination with different aromatic substances of the urine. 
It has little, if any clinical significance, but may be mistaken for glu- 
cose. It is increased after the administration of chloral, naphthol, 
phenol, menthol, camphor, oil of turpentine, morphine, antipyrine, and 
other substances. It reacts to the reduction tests with copper and 
forms a crystalline compound with phenylhydrazin, but does not fer- 
ment with yeast. It is difficult to differentiate it from the pentoses. 
Glycuronic acid itself is dextrorotatory, but its paired combinations, 
which exist in normal urine, are levorotatory. 

Cammidge's Reaction. — A number of years ago Cammidge de- 
scribed a reaction, which he observed in the urines of persons suffering 
from diseases of the pancreas, and regarded by him as useful in the 
diagnosis of pancreatic diseases. The test depends upon the produc- 



CARBOHYDRATES. 71 

tion of characteristic osazone crystals when the urine is treated with 
phenylhydrazin after boiling with hydrochloric acid. It is not as yet 
definitely settled what substance produces the reaction, but it is ap- 
parently some carbohydrate-like, possibly some dextrine-like substance. 

Cammidge claimed that his reaction is positive in all cases of pan- 
creatic diseases, but in no other diseases. Later researches, however, 
have proven that, although the reaction is given in some cases of acute 
and chronic pancreatitis, as well as in tumors of the pancreas, it is not 
pathognomic, may occur in other conditions, and may not even be 
present in pancreatic diseases. 

The urine to be examined should be from a mixed twenty-four hours' 
specimen, and must be free from albumin and glucose; if these sub- 
stances are present they must first be removed. The test can best be 
carried out in the following manner: To 40 c.c. of clear, filtered urine 
in a small flask add 2 c.c. of strong hydrochloric acid, boil for ten min- 
utes, cool, and add enough distilled water to make 40 c.c. Neutralize 
the excess of acid by adding slowly 8 gm. of powdered lead carbonate, 
allow the mixture to stand for a few minutes, then cool and filter. To 
the filtrate add 8 gm. of powdered tribasic lead acetate, filter again, 
and treat with 4 gm. of powdered sodium sulphate; heat to the boiling 
point and allow to cool. Remove the lead sulphate by filtration. 
Ten cubic centimetres of the clear filtrate are made up to 17 or 20 c.c. 
with distilled water, 0.8 gm. of phenylhydrazin hydrochlorate, 2 gm. 
of sodium acetate, and 1 c.c. of a fifty per cent acetic acid are added, 
and the mixture again boiled for ten minutes. Filter while hot, and 
make the filtrate up to 15 c.c. with warm water. When the mixture has 
cooled, a light yellow, flocculent precipitate forms, which under the 
microscope, will be found to consist of yellow crystals arranged in 
sheaves and rosettes. These crystals dissolve within a few minutes 
when treated with a thirty-three per cent solution of sulphuric acid. 

This test, when positive, can at best be looked upon as a confirma- 
tory sign in cases in which the clinical symptoms strongly point to 
pancreatic disease. It has no negative value. 



CHAPTER VII. 

OTHER ABNORMAL CONSTITUENTS. 

Acetone Bodies. — The term acetone bodies is applied to a group of 
substances, the chemical relation between which is very close; these 
substances are acetone, diacetic acid and /3-oxy butyric acid. For a 
long time /3-oxybutyric acid was held to be the mother-substance of 
the group, but it is now believed that diacetic acid is first formed and 
that the others are derived from it. Formerly these substances were 
supposed to be derived from proteins, but the present opinion is that 
their chief source lies in abnormal katabolism of fats. The presence 
of the acetone bodies in the urine, except of acetone alone in small 
amounts, is known as acidosis or acid-intoxication. In mild cases ace- 
tone, in more than small amount, occurs alone; in severer cases di- 
acetic acid is also present, and in the most marked cases /3-oxybutyrie 
acid is found with or without the others. 

The excretion of acetone bodies is especially observed in the severer 
cases of diabetes and in toxic or pernicious vomiting of pregnancy, as 
well as after death of the fcetus in utero; also in different febrile con- 
ditions, some malignant tumors, digestive disturbances, lesions of the 
central nervous system, in starvation, after chloroform narcosis, as 
well as in intoxication with various substances, such as phosphorus. 

The simpler tests for the acetone bodies are given below under the 
individual substances of this group. Two tests, however, can be de- 
scribed here which are of advantage in different conditions. Fitti- 
paldi has described an improved nitro-prusside test, which is simple 
and shows up diacetic acid as well as acetone; it takes but little time 
and the color reaction is durable. It is carried out as follows: To 4 
or 5 c.c. of urine in a test tube add 0.02 gm. of finely pulverized 
sodium nitro-prusside; mix until the salt is entirely dissolved and 
then superpose 1 c.c. of ammonia on the urine, pouring it along the 
wall of the tube. Leave the mixture undisturbed for fifteen minutes. 
At the end of this time a colored zone is present between the two fluids. 
If this zone is a yellow to chestnut color, the acetone content is within 
normal range. If the zone is of a more or less deep chestnut color, 
there is a slight excess of acetone but no diaceturia. If the zone is 

72 



OTHER ABNORMAL CONSTITUENTS. 73 

violet, there is considerable acidosis. In this case the fluid is mixed, 
and acetic acid added drop by drop, until the fluid is slightly acid. 
If the reddish-purple tint throughout the whole disappears as the acid 
is added, more or less pronounced acetonuria is present, but without 
diaceturia. If, on the other hand, the purple blends into a durable 
ruby red, there is diaceturia and, as a rule, also pronounced acetonuria. 

Clifford Mitchell* has devised a test which can be recommended in 
the acidosis of diabetes mellitus and in that of the pernicious vomiting 
of pregnancy. The foundation of the test rests upon the fact that 
urine has the property of decolorizing iodine in aqueous solution, such 
as Lugol's iodine-potassium iodide solution. Mitchell found "that the 
urine of diabetic coma, and of the pernicious vomiting of pregnancy, 
had a greater decolorizing power, as far as iodine is concerned than 
that of other conditions. In other words, the urine in the acidosis 
of diabetes and of pregnancy contains a substance which is partic- 
ularly well able to destroy the yellow color of iodine." The best 
way to apply the test is the following: To 145 c.c. of water add 
3 c.c. of Lugol's solution and 2 c.c. of a saturated solution of picric 
acid, mixing thoroughly. The result is a fine clear reddish liquid of 
bright color. Pour this liquid into a white porcelain dish and heat it 
on the water bath to a temperature of about 80° C, or if a water bath is 
not available, over the flame until fumes are abundantly given off, 
boiling being avoided by turning down the flame sufficiently. The 
urine is now added quickly from a graduated burette or a small glass 
graduate, but in small amounts at a time. In acidosis the amount of 
urine needed to turn the bright red color to a bright yellow color is 
small and the smaller the worse the case. In severe cases 2 or 3 c.c. 
of urine will cause the red color to disappear almost immediately, 
while in cases of moderate severity 8 or 10 c.c. may be required. 
Normal urines do not usually affect the color in smaller amounts 
than 15 c.c. except possibly in highly concentrated specimens, when 
only a few hundred c.c. of urine are voided in twenty-four hours. 
In most cases of normal urines, having a specific gravity of between 
1,015 and 1,020, the amount of urine required to effect the change 
from red to yellow is around 20 c.c. or considerably higher. 

There is no trouble about the end reaction, as the mixture re- 
mains fairly clear, sometimes entirely clear. If the change from 
red to yellow is not easily recognized, it will aid to have at hand in 
another white dish about 150 c.c. of a saturated picric acid solution for 
comparison. If from day to day the color is discharged by less and less 

* Clifford Mitchell: A Simple Urine Test for Acidosis. Medical Record, 
Vol. 95, 1919. 



74 URINARY ANALYSIS AND DIAGNOSIS. 

urine, the case is growing worse, but if more and more urine is required 
to turn the red to yellow, the patient is improving. 

Acetone. — Acetone (C 3 H 6 0) is found in minute amount in normal 
urine (0.01 gm. in twenty-four hours), but is considerably increased in 
many different pathological conditions. Uutil recently it was sup- 
posed to be a decomposition product of proteins, but it is now believed 
to be formed chiefly from the breaking down of fatty tissues or fatty 
foods within the organism. 

The most important pathological condition in which acetone is 
found is diabetes (diabetic acetonuria). In the milder cases of the 
disease it is not increased, but in the severer case of diabetes the 
amount of acetone excreted is usually large, and it is frequently asso- 
ciated with diacetic and /3-oxy butyric acids. Acetone in varying 
amounts is also present in the urine in different febrile conditions, in 
pneumonia, typhoid fever, scarlatina, variola, in some malignant 
tumors, in derangements of digestion, in mental diseases, after chloro- 
form narcosis, in starvation, and after poisoning with many different 
toxic substances. Urine containing a large amount of acetone has a 
peculiar, sweet, wine or fruity odor. 

The simplest method of detection is with LegaVs test: Prepare a 
fresh, strong solution of sodium nitro-prusside by dissolving a few 
fragments in a little water in a test tube. To a few cubic centimetres 
of the urine add enough liquor sodse or liquor potassae to secure a dis- 
tinct alkaline reaction, and to this add a few drops of the nitro-prusside 
solution, when a red color at once appears from creatinin. This color 
changes slowly to straw-yellow, but if acetone is present the addition 
of a few drops of concentrated acetic acid produces a purple or violet- 
red; if no acetone is present, the latter change does not occur. This 
test is not distinctive for acetone, as the reaction is also given by 
alcohol, by acetic aldehyde and by diacetic acid. 

Jackson-Taylor modified this test as follows: To a small amount 
of urine in a test tube add a few drops or even an equal amount of a 
freshly prepared sodium nitro-prusside solution. Layer this mixture 
with concentrated ammonium hydrate by pouring it along the side 
of the tube. When acetone is present a magenta color or ring is pro- 
duced at the point of contact. In the absence of acetone there will be 
no ring, or only a faint orange-red color. 

A similar modification is that of Lange: To a few cubic centimetres 
of urine add 0.5 c.c. of glacial acetic acid and a few drops of a freshly 
prepared aqueous solution of nitro-prusside. Mix thoroughly and 
overlay the mixture with 2 c.c. of ammonium hydrate. At the point 
of contact a purplish-red ring is observed in the presence of acetone. 



OTHER ABNORMAL CONSTITUENTS. 75 

Another test is Liebe?i's iodoform test, which is best applied to the 
distillate of the urine; 200 or 300 c.c. of the urine, after the addition 
of a small amount of phosphoric or hydrochloric acid in the proportion 
of 3 c.c. to 100 c.c, must be distilled and the tests performed with the 
first 10 or 15 c.c. of distillate. To the distillate add a few drops of 
strong potassium-hydroxide solution and a few drops of an iodine and 
potassium-iodide solution. If acetone is present, a yellow precipitate 
of iodoform develops at once, which can be easily identified by its 
characteristic odor and by the appearance of characteristic thin, 
yellow hexagonal plates or star-like groups under the microscope. 
The same reaction is given by other substances which may occur in 
urine, notably alcohol, but more slowly. 

This test has been modified by Gunning to prevent confusion with 
alcohol. He adds an excess of an alcoholic iodine solution and some 
ammonia to the distillate or the urine itself, and if acetone is present 
iodoform is deposited. At first the liquid often turns black from the 
precipitation of nitrogen iodide, but as the precipitate settles and dis- 
appears, the yellow iodoform deposit can easily be recognized. The 
mixture must not be warmed as long as it contains nitrogen iodide, this 
being a dangerous explosive. 

Frommer's Test. — To 10 c.c. of urine in a test tube add 1 gm. of 
potassium hydrate in the solid state, and, without waiting for a complete 
solution, treat the mixture with 10 to 12 drops of a ten per cent alco- 
holic solution of salicyl aldehyde; now warm to 70° C. If acetone is 
present an intense purplish-red ring appears at the point of contact of 
the two substances. This test is very delicate and the reaction does 
not occur with diacetic acid, as is the case with some of the other tests. 

Diacetic Acid. — The presence of diacetic or aceto-acetic acid 
(C4H6O3) in the urine is usually of grave significance. It is rarely, if 
ever, found in urine free from acetone. Diacetic acid is found in 
advanced stages of diabetes, in severe fevers, malignant scarlatina, 
diphtheria, and measles, in cancer of the stomach and intestines, as well 
as in some nervous disturbances. 

Diacetic acid decomposes rapidly and is converted into acetone 
and carbon dioxide, hence the tests for it should be carried out with 
perfectly fresh urine. 

The simplest test is Gerhardt's ferric-chloride reaction. To fresh 
urine carefully add a few drops of a ten per cent watery solution of 
ferric chloride. The first few drops produce a yellowish precipitate of 
ferric phosphate, and the addition of the reagent is continued until 
all the phosphates are removed; if diacetic acid is present, the addition 
of a few more drops of ferric chloride will produce a typical Bordeaux- 



76 URINARY ANALYSIS AND DIAGNOSIS. 

red color. If the amount of diacetic acid is small, the phosphate pre- 
cipitate should be filtered off and ferric chloride added to the filtrate. 
The red color disappears on boiling for two minutes ; this is due to the 
instability of diacetic acid, and at once differentiates the latter from 
other substances, such as salicylic acid, antipyrin acetates, and car- 
bolic acid, which give a similar reaction, but which does not disappear 
on boiling. 

When there is any doubt concerning the nature of the reaction, 
some of the urine should be acidulated with sulphuric acid and shaken 
up with ether. The ether is removed with a pipette and shaken up 
with very dilute ferric-chloride solution; if diacetic acid is present, a 
violet color results, which changes to a Bordeaux-red upon further 
addition of ferric chloride. The presence of as small an amount of 
diacetic acid as 0.01 per cent still gives this reaction. 

Another good test, which in some cases is even to be preferred to 
Gerhardt's, even though it is not as simple, is that of Arnold 
modified by Lipliawski. Two reagents are employed : first, a solution 
consisting of 1 gm. of para-amido-aceto-phenone, 100 c.c. of distilled 
water, and 2 c.c. of concentrated hydrochloric acid; second, a 1 per 
cent solution of potassium nitrite. To 6 c.c. of the first solution and 
3 c.c. of the second add an equal volume of urine and one drop of con- 
centrated ammonia; shake the mixture until it assumes a brick-red 
color. From 10 drops to 2 c.c. of this mixture, according to the 
probable amount of diacetic acid present, are treated with 15 to 20 c.c. 
of concentrated hydrochloric acid, 3 c.c. of chloroform and 2 to 4 drops 
of an aqueous solution of ferric chloride. The tube is then closed with 
a cork and gently shaken for one-half to one minute. When diacetic 
acid, even if only a trace, is present, the chloroform assumes a char- 
acteristic violet tinge; in its absence the color is yellow or light red. 
The violet persists for a long time. If the urine is highly colored, it 
is advisable to first filter it through animal charcoal. Salicylic acid, 
antipyrin, carbolic acid and other substances which may interfere with 
Gerhardt's test, do not disturb this reaction. Acetone does not give 
a positive reaction except when it is present to the extent of more than 
1 per cent, and /3-oxybutyric acid does not react at all. 

#-Oxybutyric Acid. — This acid (C 4 H 8 3 ), with acetone and diacetic 
acid, constitutes the acetone bodies; it is always associated with di- 
acetic acid in the urine. It is present in advanced cases of diabetes, 
but has also been found in scarlet fever, diphtheria, measles, scurvy, 
and other diseases. Chemically the correct term for this acid is j8- 
Hydroxybutyric acid. 

It may be detected by the method of Hart, which is the following: 



OTHER ABNORMAL CONSTITUENTS. 77 

To 20 e.c. of urine add an equal amount of water and a few drops of 
acetic acid. Boil until the volume is reduced to about 10 c.c, to remove 
acetone and diacetic acid, then add sufficient water to bring the amount 
to 20 c.c. and place 10 c.c. into each of two test tubes. To one of these 
add 1 c.c. of hydrogen peroxide, warm gently and allow to cool. 
Now apply Lange's modification of Legal's test for acetone to both 
tubes, and allow them to stand for a few hours. The tube which 
contains the hydrogen peroxide will then show a distinct red zone, 
while no reaction is seen in the other tube. 

Indican. — Indican, or indoxyl potassium sulphate (C 8 H 6 NO.S0 3 K), 
is derived from indol, a product of intestinal putrefaction of albuminous 
substances. The indol is absorbed by the blood and oxidized in the 
tissues to indoxyl, which combines with potassium sulphate and is 
eliminated in the urine. Indigo blue is formed by the oxidation of 
indoxyl potassium sulphate. 

Indican is present in minute amount in every normal urine, about 
0.015 gm. being voided in twenty-four hours with a mixed diet; the 
amount is increased up to 0.06 gm. by a meat diet. In many patho- 
logical conditions it may be considerably increased, and such an indi- 
canuria is especially pronounced in all diseases in which increased 
albuminous putrefaction in the small intestine occurs. It is found in 
all gastro-intestinal disturbances, especially obstruction in the small 
intestine, in cholera, typhoid fever, tuberculosis of the intestines, peri- 
tonitis, cancer of the stomach, liver, and intestines, as well as in many 
other diseases. 

Its detection by Jaffe's method is the following: Pour into a test 
tube a small quantity of urine and mix with an equal amount of strong- 
hydrochloric acid; add ten or fifteen drops of chloroform and, drop by 
drop, a moderately strong fresh solution of chloride of lime, shaking 
after each drop. The chloroform readily dissolves the freshly formed 
indigo, and a blue color appears, which is more or less pronounced, 
according to the amount of indican present. Instead of chloride of 
lime (calcium hypochlorite) a 0.5 per cent solution of permanganate of 
potash, kept in a dark bottle, may be used. The chloroform may be 
added after the chloride of lime or permanganate of potash. Five 
drops of the latter to 10 c.c. of urine are sufficient. 

Another good test is that of Obermayer: Precipitate 20 c.c. of urine 
with 5 to 10 c.c. of a ten per cent lead-acetate solution and filter; add 
an equal volume of fuming hydrochloric acid containing 2 gm. of ferric 
chloride to 1 litre of HC1; shake thoroughly and add 5 c.c. of chloro- 
form; again shake. This extracts the indigo, and the blue chloroform 
solution settles at the bottom of the test tube. With normal urine a 



78 URINARY ANALYSIS AND DIAGNOSIS. 

faint blue color results, while an increase of indican gives a dark blue 
color. 

This test can be simplified in the following manner : Have on hand 
Obermayer's reagent which consists of a 0.2 per cent solution of dry 
ferric chloride in concentrated hydrochloric acid (ferric chloride 1.0 
gm., HO, 500 c.c.) and keeps indefinitely. To 5 c.c. of urine add an 
equal amount of this reagent and 10 to 15 drops of chloroform; shake 
thoroughly. The chloroform becomes blue in proportion to the indi- 
can present; the color increases upon standing. The test is a more 
reliable one than Jaffe's method. Instead of using Obermayer's re- 
agent as such, the urine may be mixed with an equal amount of strong 
hydrochloric acid in a test tube, and 1 or 2 drops of a ten per cent solu- 
tion of ferric chloride then added to the mixture. The amount of 
chloroform to be used remains the same. If the urine is quite dark in 
color or if bile pigment is present, the pigments may be removed by 
adding a solution of lead subacetate and filtering. 

When potassium iodide has been taken internally, the chloroform 
becomes reddish or red instead of blue, due to the liberation of free 
iodine, the intensity of the red color varying with the amount of indi- 
can. When thymol has been added to the urine as a preservative, the 
color is violet. When formalin has been used as a preservative, in- 
dican cannot be detected by these methods. 

A more sensitive test for indican than either Jaffe's or Obermayer's 
is that of Jolles: To 10 c.c. of urine add 2 c.c. of a twenty per cent lead 
acetate solution, shake and filter. To the nitrate add 0.5 c.c. of a 
ten per cent alcoholic solution of thymol, 10 c.c. of Obermayer's re- 
agent and 4 c.c. of chloroform; mix thoroughly. In the presence of 
even minute traces of indican, the chloroform is colored a pronounced 
violet. 

Skatoxyl potassium sulphate (CgHgNO.SOsK) is formed in varying 
amount from skatol, which like indol is a product of intestinal putre- 
faction of protein substances. As a rule this pigment is present in 
smaller quantities than the indoxyl potassium sulphate, but occasionally 
appears in the urine in excess of the indican, and then the chloroform 
assumes a distinct red color instead of a blue. Clinically the sub- 
stance is of little interest, and is known as indigo-red, skatoxyl-red or 
uro-rubin. 

Ehrlich's Diazo Reaction. — The diazo reaction was suggested by 
Ehrlich as a valuable adjuvant in the diagnosis of typhoid fever. The 
nature of the substance upon which the reaction depends is uncertain. 
Some claim that a positive reaction indicates an abnormal decomposi- 
tion of protein material, while others suppose it to be due to an in- 



OTHER ABNORMAL CONSTITUENTS. 79 

creased excretion of alloxyproteic and other acids. It is not character- 
istic for typhoid fever, and is frequently enough absent in even pro- 
nounced cases of the disease; when present, it usually disappears at 
the end of the third week, but may reappear in a relapse. 
The solutions necessary for the reaction are two: 

1. Diazo reagent: 

Sulphanilic acid . 25 to 1 . 25 gm. 

Hydrochloric acid, concentrated 12.5 c.c. 

Distilled water 250 . c.c. 

2. Sodium nitrite 0.1 gm. 

Distilled water 20 . c.c. 

These solutions keep best in dark bottles and must be kept sepa- 
rately. When needed, mix 50 c.c. of the diazo reagent with 1 c.c. of 
the sodium-nitrite solution. 

The test is performed by mixing 10 c.c. of the urine with 10 c.c. of 
the mixed reagents, quickly adding 2 c.c. of a ten per cent ammonia 
solution. If the reaction is positive the solution assumes a carmine- or 
deep cherry-red color, which also appears in the foam. A coffee-brown 
color is not indicative of a positive reaction. On standing for twenty- 
four hours a dark green precipitate is formed when the reaction is 
positive. 

The diazo reaction has also been found in measles, pneumonia, 
scarlet fever, erysipelas, typhus, puerperal septicaemia, syphilis, 
cancer, and especially tuberculosis; in the latter disease the presence 
of the reaction is frequently an unfavorable sign, as it has been often 
found in cases with a rapidly fatal termination. 

Different drugs, such as opium, morphine, chrysarobin, naphthalin, 
and heroin, when taken internally give the diazo reaction, though here 
a green precipitate does not, as a rule, occur on standing for twenty- 
four hours. Other drugs, such as tannin, creosote, guaiacol, and salol, 
render the diazo reaction in urine negative — a point to be remembered 
in tuberculosis, where a number of these drugs are frequently given. 

Coloring Matters. — Bile Pigments. — When biliary coloring matters 
appear in the urine, the urine always has an abnormal color — dark 
yellow, brown, or greenish — and a yellow or yellowish-green froth or 
foam is produced by shaking. In fresh urine bilirubin is usually 
found in combination with alkalies ; if allowed to stand exposed to the 
air, bilirubin becomes oxidized to the green biliverdin, as well as to the 
less important oxidation products, biliprasin, bilifuscin, bilihumin, 
bilicyanin, and choletelin. When a considerable amount of the pig- 
ment is present in the urine, the morphological elements of the sedi- 



80 URINARY ANALYSIS AND DIAGNOSIS. 

ment often have a more or less pronounced yellow or brownish color. 

Bile pigments are met with in the urine in all cases in which there is 
an obstruction to the outflow of bile from the liver, and are seen in 
numerous pathological conditions of the liver, with or without the 
presence of jaundice. They may, furthermore, appear as a result of 
blood changes and after hemorrhage into the tissues. The condition is 
known as choluria. 

The presence of biliary pigments in the urine can frequently be 
detected by the color of the urine and the foam, as well as by the 
yellow appearance of the elements in the sediment under the micro- 
scope. One of the best methods for detecting bile pigments in the 
urine is by Gmelin's test, which consists in placing a small quantity of 
strong nitric acid, containing a little yellow nitrous acid, into a test 
tube and gently floating a similar amount of urine upon it. If biliary 
coloring matters are present, a set of concentric colored rings will 
appear at the point of union between the acid and the urine; these 
rings, from above downward, will be green, blue, violet, red, and yellow, 
the green being the most predominant, and is indispensable in proving 
the presence of bile, the others being sometimes more or less indistinct 
and even entirely absent. A moderate amount of albumin has no 
influence upon this reaction. 

A modification of this test by Rosenbach is also good: The urine is 
filtered through pure white filtering paper, and, after filtration, a drop 
of the acid is applied to the inside of the filter; around the nitric acid 
the same concentric rings will be observed. 

Another simple test is Ultz'mann's: To 10 c.c. of urine add 3 or 4 c.c. 
of a twenty-five per cent caustic-potash solution and an excess of pure 
hydrochloric acid. If bile pigments are present, the mixture assumes 
a beautiful green color. 

Besides bile pigments, bile acids may be found in the urine with the 
pigments in pathological conditions of the liver. Their occurrence, 
however, is rare and their detection of no clinical value. 

Coloring Matter of Blood. — Haemoglobin, the chief coloring matter 
of the blood, may be found in the urine, either enclosed in the red blood 
globules, in cases of hematuria, or in rare instances dissolved in the 
urine, the affection being called hemoglobinuria. When a small 
amount of blood is present in the urine, the color of the urine is not 
necessarily changed, and a slight cloudiness alone may or may not be 
found; when a large amount of blood is present, however, the color of 
the urine, as well as that of the sediment, is brown, reddish-brown, 
or red. 

Hsematuria is common, may be due to many different causes, such 



OTHER ABNORMAL CONSTITUENTS. 81 

as severe inflammations, concretions, calculi, tumors, traumatism, 
tuberculosis, etc., and may occur from any portion of the genito- 
urinary tract. The source of the hemorrhage can be positively diag- 
nosed only from the epithelia and other elements in the sediment 
under the microscope, as the macroscopic characteristics, from which 
it is claimed the source of the blood can be diagnosed, are in many 
cases entirely unreliable. 

Haemoglobinuria is due to a dissolution of the red blood corpuscles 
in the blood-vessels, which permits the coloring matter to escape in 
solution. In this condition blood corpuscles are scanty or entirely 
absent; when present, they are quite pale and not easily recognized. 
Hemoglobinuria is occasionally found in severe infectious diseases, 
such as yellow fever, malignant smallpox, and scarlet fever; in extensive 
burns and after poisoning with different substances, such as carbolic 
acid, phosphorus, and naphthol. Cases of paroxysmal hsemoglobin- 
uria also occur. 

The simplest method of detecting haemoglobin in urine is the 
boiling test: When urine is boiled and a few drops of acetic or nitric 
acid are added, the albuminous precipitate, always present in such 
cases, is not white, but has a more or less pronounced brown or 
brownish-red color. 

Heller's Test. — The earthy phosphates are precipitated from the 
urine by the addition of caustic potash or soda and heat; as they be- 
come precipitated they carry with them the coloring matter, and are 
therefore not white, but blood-red. Under the microscope the coloring 
matter can easily be detected whenever present in any form. 

Almens' Guaiacum Test. — Thoroughly mix equal parts of tincture 
of guaiacum (1 part of guaiacum to 100 parts of absolute alcohol) and 
old oil of turpentine; upon this mixture, which must not have any blue 
color, layer the urine to be tested. If haemoglobin is present, first a 
bluish-green and then a light or dark blue ring appears at the point of 
contact; on shaking, the mixture becomes blue. Urine containing 
many pus corpuscles also gives a blue ring with this test, which, how- 
ever, disappears on heating the mixture to the boiling point. 

Hcematoporphyrin, & derivative of hsemoglobin, and urobilin, de- 
rived from bile and blood pigments, have been previously described. 

Melanin is a dark pigment of slight clinical importance, and is only 
rarely found in urine; it may occur in the urine of persons suffering 
from melanotic sarcoma or cancer, though it is not present in all cases 
of this kind, and has also been observed in different wasting diseases. 
The urine containing melanin is not usually dark when voided, but 
soon becomes so upon exposure to the air; upon the addition of oxidiz- 



82 URINARY AX ALT SIS AXD DIAGXOSIS. 

ing agents, such as ferric chloride, sulphuric acid, or bromine, the dark 
color appears more rapidly and intensely. Melanin is present in the 
urine as a chromogen — melanogen — which becomes oxidized to 
melanin. 

Alkapton is occasionally found in urine in different disturbances 
of protein metabolism and causes the mine to turn dark upon standing 
or the addition of an alkali. Alkaptonuria depends upon the presence 
of hydroquinon-acetic acid (homogentisic acid) and uroleucinic acid. 
The substance reduces Fehling's solution but is not affected by bismuth 
solutions. It is of no practical interest. 

Fatty Matters. — In rare cases a varying amount of fat, rendering 
the urine more or less turbid, may be found. Such a condition, in 
which the fat is present either in a state of minute subdivision or in the 
form of larger oil drops, is called lipuria when no albumin is present, 
or chyluria when a large amount of albumin is found with an abundance 
of small fat globules. In both lipuria and chyluria, cholesterin, usually 
in small amount only, may be present in the urine. 

The addition of ether quickly dissolves the fat, and the urine be- 
comes clear. The microscope will reveal the presence of fat and 
cholesterin at once. 

Leucin and tyrosin are products of decomposition of the albumins. 
They usually occur together in the urine and are mostly found in rap- 
idly destructive processes of the liver, such as acute yellow atrophy 
and phosphorus-poisoning, although occasionally seen in other diseases. 
They can easily be detected by microscopical examination. 

Cystin. — Cystin (C6H12X2O4S2) occasionally appears in a number 
of members of the same family. It is not a normal ingredient of urine, 
and its chief clinical significance lies in its tendency to form calculi. 
Urine containing cystin may have a peculiar odor, a greenish-yellow 
color, and develops the odor of sulphuretted hydrogen upon standing; 
a grayish-white precipitate may form. When cystin is present, certain 
products of intestinal putrefaction, the diamins, especially cadaverin 
and putrescin, are almost constantly found. The neutral sulphur of 
the urine is greatly increased in amount in these cases of cystinuria. 
Cystin is soluble in ammonia and can be precipitated by acetic acid. 
Its microscopical appearance is quite characteristic. 



PART SECOND. 

MICROSCOPICAL EXAMINATION. 



PART SECOND. 

MICROSCOPICAL EXAMINATION. 



CHAPTER VIII. 

GENERAL CONSIDERATIONS. 

Microscopical examination of urine is in many cases of greater diag- 
nostic importance than chemical examination, and should in every in- 
stance form a part of urinary analysis. To obtain a sediment, urine, be- 
fore it is to be examined under the microscope, can be set aside in a well- 
stoppered bottle or conical vessel, preferably in a cool place, for at least 






Fig. 15. — Sedimentation Glass. 



Fig. 15a- — Spaeth's Sedimentation Glass. 



six, but better twelve, hours. If a conical vessel is selected, either a plain 
sedimentation glass (see Fig. 15) or Spaeth's improved sedimentation 
glass (see Fig. 15a) may be used. The latter has a perforated stopper at 
the bottom, and offers advantages over the ordinary form, in that the 
sediment is collected in the stopper and can be removed with it. At the 
end of this time it will be seen that in every urine, even if perfectly nor- 
mal, a sediment has appeared at the bottom of the bottle, which is to be 
used for microscopical examination. This sediment in normal urine will 
be in the form of a cloudy deposit, the nubecula, and consists of mucus, 
flat epithelia from the bladder and vagina, and a varying number of epi- 

85 



86 



URINARY ANALYSIS AND DIAGNOSIS. 




dermal scales from the genital organs. Spermatozoa may be present in 
both male and female urine after sexual intercourse, and in the former 
after nocturnal emission. The sediment of normal urine may, further- 
more, contain even a large number of salts 
in the early morning, when the urine is highly 
concentrated, while these salts may be almost 
entirely absent at other times. 

After standing for some time, every urine 
undergoes a change, the rapidity of which 
depends upon the temperature as well as 
upon the degree of the reaction when passed. 
An acid urine, which is perfectly clear when 
passed, may become turbid upon cooling, 
owing to the presence of a large amount of 
urates. Micro-organisms, especially of the 
class of hyphomycetes or mould fungi, and 
saccharomycetes or yeast fungi, may sooner 
or later develop, and in a small degree 
schizomycetes, or fission fungi. An ampho- 
teric or even faintly alkaline urine may be 
clear when voided, but soon becomes more 
or less cloudy, the change depending partly 
upon the salts, but mostly upon the development of bacteria belonging 
to the class of fission fungi. This change takes place quickly in warm 
weather, and is, as a rule, more pro- 
nounced in the urine of females than in 
that of males, on account of the bacteria 
which are normally found in the vagina. 
In pathological conditions the sedi- 
ment in the urine is usually more or 
less increased, though in mild cases the 
increase is not pronounced. In severe 
inflammatory or suppurative processes, 
however, it may be very abundant, 
this being due to pus corpuscles, blood 
corpuscles, epithelia, casts, etc., which 
it contains. Frequently such urine is 
cloudy when voided, and, when an ex- 
cessive amount of mucus is present, is fig. 17. 
ropy in character. 

Use of Centrifuge. — To overcome the necessity of waiting for pre- 
cipitation to take place and to avoid the changes due to decomposition, 



Fig. 16. — Hand Centrifuge. 




-Water-power Centrifuge. 



GENERAL CONSIDERATIONS. 



87 



the centrifuge is considerably used. With this instrument three minutes 
are sufficient to obtain a proper sediment. The simplest centrifuge is 
operated by hand (see Fig. 16). Single-speed instruments give a speed 
up to 1,500 revolutions a minute; double-speed instruments, 1,000 to 
4,000 revolutions. The former answers all ordinary purposes. The 
water-power centrifuge (see Fig. 17) is also easy to operate, giving a 
smooth and rapid motion; ordinary water pressure is sufficient to obtain 
the desired speed. Where electricity is ob- 
tainable, the electric centrifuge is the most sat- 
isfactory. The sedimentation tubes, supplied 
with the instrument (see Fig. 18), are either 
plain or graduated, and hold 15 c.c. The in- 
strument undoubtedly has its advantages, but 
in some cases it is better to adhere to the old 
method and wait for six hours, the only pre- 
cautions necessary being to keep the bottle 
tightly corked and in a cool place. 

One of the chief advantages of the cen- 
trifuge is that bacteria are thrown down in 
large numbers, so that the search for them is 
more successful. This is especially important 
in cases of suspected tuberculosis, as tubercle 
bacilli are found more readily in centrifugal- 
ized than in non-centrifugalized urine. 

On the other hand, the great force necessary 
to effect sedimentation will undoubtedly change 
some of the minute elements to a greater or less 
degree. Some of the pus corpuscles may assume different shapes, irregu- 
lar in character, partly due to commencing disintegration. These changes 
are not present in the non-centrifugalized specimen, while the number of 
corpuscles is the same in both. Similar changes may take place in differ- 
ent epithelia as well as in spermatozoa, which latter may assume peculiar 
forms after the use of the centrifuge. When a proper sediment is ob- 
tained by standing, the number of casts in the centrifugalized and non- 
centrifugalized specimens is practically the same in a given case, though 
here, too, some may undergo changes by centrifugalizing. Mucus-threads 
are more abundant and more likely to take on the form of cylindroids, 
and this may be quite pronounced in healthy urines, in which no patho- 
logical features are present; these cylindroids often resemble hyaline 
casts to such a degree as to be easily mistaken for them. Extraneous 
fibres, such as linen fibres, easily break into minute fibrillar, and resem- 
ble connective-tissue shreds when the latter are not present. 




Fig. 18. — Sedimentation 
Tubes for Centrifuge. 



88 URINARY ANALYSIS AND DIAGNOSIS. 

When care is exercised in microscopical examination and only the 
perfectly distinct features are taken into consideration, the centrifuge 
is decidedly advantageous, but in some cases it is better to adhere to 
the old method of obtaining the sediment by gravity. 

Mounting of Sediment. — The sediment having been obtained by 
either allowing at least four or six ounces of urine to stand at rest for the 
required time or by the use of the centrifuge, a drop of it is transferred 
to a slide for microscopical examination. For this purpose a glass pipette, 
consisting of a simple glass tube drawn to a moderately fine point at one 
end, may be used. This tube is passed into the urine with the upper 
opening closed by one finger, until it almost touches bottom, when the 
pressure of the finger is gently relaxed, a small amount of the sediment 
from different layers drawn into the tube, the latter closed again with the 
finger, and withdrawn. A better method is carefully to decant the upper 
portion of the urine, pour the sediment into a small dish, and use a 
earner s-hair brush to transfer a drop to the slide. Such a brush can be 
thoroughly cleansed with water after each examination, and is kept clean 
more easily than a pipette. The drop of urine is put into the centre of the 
slide and a cover glass slowly dropped upon it, great care being taken not 
to press the cover down, since even the small amount of force used may 
be sufficient to change the epithelia or casts. Some workers never use 
cover glasses, but examine the urine upon the slide without covering it. 
This method is uncleanly and should never be employed. 

Use of Antiseptic Substances. — In order to avoid decomposition of 
the urine as much as possible, when it cannot be examined within twelve 
or twenty-four hours after being passed, large numbers of antiseptic sub- 
stances, such as salicylic acid, boric acid, chloroform, thymol, formalin, 
and bichloride of mercury have been recommended to be added in small 
amount to the urine; but when not absolutely necessary, it is better to 
avoid them. Of these substances thymol is the best, a small crystal being 
sufficient. The use of formalin should be avoided, as it is apt to change 
a number of the ingredients of the urine. Urine kept in a cool place and 
in a clean bottle can be examined, even thirty-six hours after being void- 
ed, without the danger of having to deal with too many putrefactive 
changes. In all cases the chemical analysis should be made as soon as 
possible. The sediment for microscopical examination can be mixed 
with a little alcohol if necessary, or, still better, chromic acid. 

Preservation of Sediment. — If it is desired to preserve a specimen 
for a variable length of time, the best method is to add from two to five 
drops of a five per cent chromic-acid solution to it; the only change that 
will take place is that the albumin becomes coagulated, appearing under 
the microscope in the form of irregular granular matter, irregularly scat- 



GENERAL CONSIDERATION. 89 

tered throughout the field. The chromic acid will preserve all the feat- 
ures permanently, not even causing any changes in the casts. Perma- 
nent microscopical or slide specimens are made by adding a few drops of 
chemically pure glycerin to a small amount of the sediment previously 
treated with chromic acid, until a jelly-like mass is formed, and waiting 
for a few days until all the superfluous water has evaporated. It is not 
advisable to add the glycerin to the sediment mixed with chromic acid 
until the watery element of the urine has become evaporated, which will 
be the case at the end of four or five days. If the sediment has become 
too thick on account of the evaporation, a little more glycerin is added, 
a drop then mounted upon a slide, a cover glass placed upon it, and the 
whole surrounded by asphalt. Specimens preserved in this manner can 
be kept for many years without change. 

Should it be desired to preserve a large amount of the urinary sedi- 
ment in a bottle, the chromic acid is added as before; but in that case it 
will be better to add a larger amount of a weaker solution (about one- 
fourth or one-half per cent). After a few weeks the upper part of the 
liquid is poured off and a small amount of a forty or fifty per cent solu- 
tion of alcohol added, to prevent the growth of mildew. Microscopical 
specimens can be made years afterward from urine so preserved, by tak- 
ing a drop of the sediment, mixing it with a drop of glycerin, and mount- 
ing upon a slide in the regular manner. 

Another method, which preserves the elements fairly well, consists in 
treating the sediment with equal parts of Hay em's liquid, composed of 

1 gm. of sodium chloride, 5 gm. of sodium sulphate, 0.5 gm. of corrosive 
sublimate, and 200 c.c. of water. 

Use of Microscope and Magnifying Powers. — Every complete mi- 
croscope is provided with two eyepieces or oculars, three objectives, 
also called lenses, a triple nose-piece and a substage with an Abbe 
condenser. Of the two oculars one is short (1 inch), the other long 
(2 inches). While these are still arbitrarily marked by some foreign 
makers, American makers have adopted a rational system of marking 
them in accordance with their initial magnification; the short eyepiece 
has an initial magnification of eight or ten diameters (8x or lOx), 
the long eyepiece of four or five diameters (4x or 5x). The three ob- 
jectives are usually 16 mm. (f inch), 4 mm. (£ inch), and 1.9 or 

2 mm. (Vt inch); the first two are dry objectives, the last is an oil 
immersion objective, also known as an homogeneous immersion objec- 
tive. These objectives are attached to the nose-piece, which is of the 
revolving variety, so that one objective can immediately be replaced by 
another. The purpose of the substage condenser is to condense the 
light and thus give an amply illuminated field when the illumination is 



90 URINARY ANALYSIS AND DIAGNOSIS. 

otherwise insufficient; this becomes necessary only when the oil im- 
mersion objective is used. The condenser should not be used with the 
ordinary 16 mm. and 4 mm. dry objectives, but should always be 
removed when working with these objectives. 

The mirror below the stage for the proper illumination is plane on 
one side and concave on the other; the concave mirror should always be 
used with the dry objectives when the substage condenser has been 
removed, while the plane mirror is best for work with the condenser, 
that is, for high magnifying powers with the immersion objective. 
Every microscope is usually supplied with two diaphragms, one im- 
mediately below the stage, or rather on a level with the stage, the other 
below and in connection with the Abbe condenser. Both diaphragms 
may be iris diaphragms, which consist of a series of thin overlapping 
blades placed around a central opening, the size of which may be varied 
by means of a lever operating the blades. In some of the micro- 
scopes only the lower diaphragm is an iris, while the upper is of the 
so-called cap variety, which requires a separate piece for each aper- 
ture, and which is held by a special substage receiver. As a rule, 
there are three cap diaphragms, each one having an aperture of dif- 
ferent size, which, when attached, are located immediately below and 
near the object. The middle sized aperture is, as a rule, the best for 
moderately high magnifying powers, obtained by using the 4 mm. dry 
objective. When the immersion objective is used, and the micro- 
scope contains two iris diaphragms, the upper iris must be opened com- 
pletely, while the aperture of the lower is regulated in accordance with 
the amount of light required. The cap diaphragms must always be 
removed before the substage condenser can be adjusted. 

All the complete microscopes are supplied with a rack and pinion 
coarse adjustment and a fine adjustment or micrometer screw. They 
are also provided with an inclination joint, by which the body of the 
microscope can be inclined to any angle between the perpendicular and 
horizontal. As a rule, a slight inclination of the microscope is advisable 
and more comfortable than an upright position of the tube. 

In working with the microscope adjust the mirror so as to obtain 
the best light, using daylight whenever possible, but avoiding the use 
of direct sunlight. As to the use of artificial light, both electric light, 
gas light, especially a Welsbach burner, or even an ordinary oil lamp 
may be used. Always work with both eyes open; never close one eye. 
Place the slide specimen on the stage, fastening it with the clips, focus 
the body tube down by means of the coarse adjustment until the ob- 
jective is within a short distance of the specimen; now look through the 
eyepiece and slowly elevate the tube with the coarse adjustment, 



GENERAL CONSIDERATIONS. 91 

until the specimen is brought fairly well into focus; use the fine adjust- 
ment to obtain the sharpest focus. Always keep two fingers of the 
left hand, preferably the thumb and index finger, on the micrometer 
screw, so as to constantly retain a perfectly clear focus, remembering 
that the fine adjustment has only a limited range and must only be 
turned to a slight degree in either direction. If the features in the 
specimen become lost to view completely, no attempt should be made 
to obtain a clear field again with the fine adjustment, but the coarse 
adjustment should be used in the manner explained above. Two fin- 
gers of the right hand should be used to move the specimen about 
slowly, so that its different fields are gradually brought into view. A 
mistake frequently made with urine specimens is that instead of focus- 
ing the object itself, the top of the cover glass is brought into focus. 
Minute dust particles are always present on the top of the cover glass, 
and these may take on the most varied appearances, frequently re- 
sembling crystals of different kinds. Such dust particles, however, 
always have a peculiar grayish appearance, even though their shapes 
and sizes vary. When not absolutely certain that the correct focus 
has been obtained, it is always advisable to draw the tube up with 
the coarse adjustment, and then repeat the process of obtaining the 
correct focus. 

Great difficulty is frequently encountered in finding all the fea- 
tures present in a specimen of urine under the microscope, or in 
diagnosing them correctly, this being in many cases due to the want 
of a proper magnifying power. For the study of urine, the magnify- 
ing power should alwaj^s be between 400 and 600 diameters, the aver- 
age being 500; such a magnifying power is obtained by the use of a 
4 mm. dry objective and a short eyepiece; the Abbe condenser should 
always be removed, since too much light is obtained with it and the 
definition of the features in urine work is much clearer without it. 
The general custom of examining urine specimens with low magni- 
fying powers, about 100 diameters, using the 16 mm. objective, cannot be 
recommended, since the majority of the features present in urine can- 
not be differentiated with such a low power, and even casts cannot 
always be diagnosed with certainty. 

Again, there are many different features as well as extraneous 
matters, which resemble casts with low power, but which are not 
tube-casts; their positive differentiation is only possible with higher 
magnifying powers. Under no circumstances should the study of a 
specimen of urine ever be attempted without the drop upon the slide 
first being covered by a cover glass and evenly spread out. It is 
absolutely impossible to obtain a satisfactory specimen without this, 



92 URINARY ANALYSIS AND DIAGNOSIS. 

not to speak of the uncleanliness of such a method, and the ease with 
which an objective can be soiled. 

When a urine specimen is to be studied for micro-organisms, 
smears of the centrifugalized specimen must be made, fixed and 
stained. Staining of a urine specimen except for bacterial examination 
is not only unnecessary but positively misleading. Specimens stained 
for micro-organisms are best examined with the oil immersion objec- 
tive, and for this purpose the Abbe condenser is essential. While 
both tubercle bacilli and gonococci can be seen with a power of 500 
or 600 diameters in a well stained specimen, their study with a mag- 
nifying power of 900 or 1000 diameters, as obtained with the oil 
immersion objective and the short eyepiece is far more satisfactory. 

In studying a specimen under the microscope it will be found of 
great advantage to keep a record of all the features as they are found, 
and also to note their comparative numbers. Too much stress cannot 
be laid upon the fact that, in the study of the cellular elements, the 
comparative sizes of corpuscles and epithelia, especially the smaller 
varieties, can alone lead to correct diagnoses. Such a differentia- 
tion is only possible when magnifying powers of at least 400, but prefer- 
ably 500, diameters are used. 



CHAPTER IX. 

CRYSTALLINE AND AMORPHOUS SEDIMENTS. 

The crystalline and amorphous or chemical sediments found in urine 
are mostly the different acids and salts, though a number of other unor- 
ganized sediments may also be present. 

I. ACIDS AND SALTS. 

The salts which may be found under the microscope are seen partly 
in acid and partly in alkaline urine, and the sediments are the following: 

A. ACID SEDIMENTS. 



Common 



1. 


Uric acid 




2. 


Sodium urate 
Amorphous 


C 


3. 


Calcium oxalate 




4. 


Cystin 


5. 


Creatinin 


6. 


Hippuric acid 


7. 


Leucin 


8. 


Tyrosin / 


9. 


Calcium sulphate 


10. 


Sodium urate 




Crystalline 


, 



- Rare 



B. ALKALINE SEDIMENTS. 



1. Triple phosphates or ammonio-magnesian 1 
phosphates 
(a) Complete 



(6) Incomplete 

2. Simple phosphates or calcium phosphates 

(a) Amorphous 

(6) Star-shaped, or stellate 

3. Ammonium urate 

4. Calcium carbonate. — Less common. 

5. Magnesium phosphate. — Rare. 



I Common. 



A. ACID SEDIMENTS. 



1. Uric Acid. — Uric acid is a constant ingredient of the urine, and is 
frequently seen under the microscope. Its amount is greatly increased 
by an abundant protein diet, such as meat, especially with diminished 

93 



94 



UEINAEY ANALYSIS AND DIAGNOSIS. 



exercise or sedentary habits. It is also augmented in acute febrile dis- 
eases and in impeded function of the heart, lungs, and kidney. It is 
diminished by a diet poor in protein matters; also in chronic kidney dis- 




Fig. 19. — Crystals of Uric Acid, Common Form (X 400). 



eases and other diseases in which the amount of urea is diminished. The 
precipitation of a large amount of uric acid does not necessarily signify 
an increase in its elimination. 

Uric acid varies greatly in shape and size, and is of a yellowish-brown 
or reddish-brown color, except when precipitated in very thin plates, 
when its color is pale yellow, or it may appear almost colorless. Different 
varieties of uric acid are met with, some of which are frequently seen and 
constitute the common forms, while others are found more rarely. When 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 95 

present in larger amount it becomes precipitated in the form of reddish 
masses, which adhere to the sides of the vessel and produce the so-called 
brick-dust sediment. These masses are known as gravel or sand. 

The common form of uric acid (see Fig. 19) consists of rhomboidal 
prisms — lozenge shape. The lozenges may be large or small, single or 



Fig. 20. — Crystals of Uric Acid, Common Form ( X 400). 

multiple, with round or pointed ends, being at times more or less irregu- 
lar. There may be two lozenges together, giving the twin form, or they 
may be seen either half-edge or edgewise, or they may be in more or less 
regular barrels. Besides these, complicated formations, crosses, and ro- 
settes, are seen (see Fig. 20), the latter being a conglomeration of lozenges, 



96 



URINARY ANALYSIS AND DIAGNOSIS. 



either in front view or edgewise, and frequently smaller crystals, some- 
times quite irregular, are found within the larger ones. 

Another form (see Fig. 21) is often seen in highly acid urine, and is 
usually found with gouty or rheumatic processes or with the formation 




Fig. 21. — Crystals of Uric Acid, from Highly Acid Urine (X 450). 



of uric-acid concretions in the bladder. These crystals appear in peculiar 
spear, comb, and brush shapes or in exaggerated lozenges. The spear 
shapes are in many cases very pronounced. In persons in whom the so- 
called uric-acid diathesis exists, these forms are frequently seen. 

Still another variety of uric acid (see Fig. 22) consists of concretions 
of varying sizes, irregular plates, masses, and needles, either single, 



CRYSTALLINE AND AM0EPH0U8 SEDIMENTS. 



97 



double, or conglomerated in the form of stars. Occasionally dumb-bell 
forms are also met with. The passage of such concretions or gravel 
proper, when at all abundant, is almost invariably accompanied by more 
or less severe pain. When in larger masses, we have the uric-acid cal- 




Fig. 22. — Uric-acid Concretions (X 500). 



culi or stones, which form the largest number of renal stones, being per- 
haps seventy per cent of all calculi passed. 

Quite frequently small, irregular plates of a light or dark yellow color 
are seen under the microscope; the sediment in which these are found 
may be of a mucous or granular character, which gives no indication of 
containing any uric acid. Different varieties of uric acid with calcium- 
oxalate crystals and occasionally a varying amount of urates are not in- 



98 



URINARY ANALYSIS AND DIAGNOSIS. 



frequently met with in the same specimen. When these features are 
present, the diagnosis of lithccmia is justified. 

Although in almost all cases there will be no difficulty in recognizing 
uric acid under the microscope, there may be extremely pale, practically 
colorless lozenges or irregular plates which might be mistaken for phos- 




Fig. 23. — Pale Uric-acid Crystals (X 500). 



phates or imperfect calcium-oxalate crystals. In Fig. 23 pale crystals of 
different sizes and shapes are depicted. In order to ascertain their exact 
character, a small amount of some alkali, such as caustic potash or soda, 
may be added while the specimen is examined under the microscope, 
when the uric-acid crystals will be seen to dissolve readily. If now a 
drop or two of acetic acid be added, small characteristic crystals will 
soon reappear. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 99 

2. Sodium Urate. — Sodium urate (see Fig. 24), when present in large 
amounts, forms the so-called clay-water sediment, which renders the urine 
turbid upon cooling. It may be found alone or in combination with 
uric acid and potassium urate, from which latter it can hardly be distin- 
guished. Such a sediment is the so-called sedimentum lateritium. Sodium 
urate usually consists of groups of light or dark brown, fine, amorphous 
granules in a moss-like arrangement, which easily adhere to foreign sub- 
stances as well as to mucus and epithelia. The groups vary greatly in 
size and are at times quite large. 

This salt is of common occurrence, and is found in all slight febrile 
derangements, after mental and physical exertion, in colds, catarrhs of 

& *• & &.. ■& •* _. 




- 



.Fig. 24. — Sodium Urate, Amorphous (X 500). 

the stomach and intestines, on the first day of menstruation, and in gen- 
eral malaise; and it may also occur in perfectly healthy individuals 
where the urine is highly concentrated. It is held in solution while the 
urine is warm, but quickly becomes precipitated upon cooling. It is the 
effete material of oxidation, the so-called materia peccans of old physicians. 
In rare cases sodium urate is crystalline (see Fig. 25), appearing in 
the form of needle-like clusters or arranged like sheaves of wheat, or of a 
fan-shape arrangement, pointed toward the centre, and broader toward 
the periphery. This sediment has been found in various conditions, such 
as diseases of the stomach and intestines, and in healthy individuals dur- 
ing prolonged physical exertion. The accompanying illustration was 



100 



URINARY ANALYSIS AND DIAGNOSIS. 



taken from a case of dermoid cyst of the kidney, where the crystals oc- 
curred in large numbers with uric-acid crystals. 

Sodium urate frequently undergoes a change a few hours after the 
urine is voided, the length of time required for the change depending upon 




Fig. 25. — Sodium Urate, Crystalline (X 500). 



the temperature. The granules commence to change into small brown 
globules, which are either single or grouped in twos; the latter soon coal- 
esce and form small dumb-bells, which gradually enlarge (see Fig. 26). 
This has been spoken of as the first stage of the formation of ammonium 
urate, the ammonium urate in statu nascenti, and denotes a commencing 
transition of the original acid sediment into an alkaline. When the alka- 
line change is more or less complete, we have the fully formed globules 
of ammonium urate. 

3. Calcium Oxalate. — Calcium oxalate, when present in small or 
moderate amount in the urine, without an increase of specific gravity, 
has no clinical significance. Oxalic acid, normally present in all urine in 
small quantities, has a special affinity for calcium, and appears in the 
urine as calcium oxalate. It is frequently found after eating certain kinds 
of fruits and vegetables, such as apples, oranges, bananas, certain berries, 
grapes, tomatoes, rhubarb, asparagus, spinach, and turnips. 

It occurs in a variety of forms (see Fig. 27), but it is always colorless 
and of a moderately high degree of refraction. The most common forms 
are those of quadrilateral octahedrons, greatly varying in size, with single 
or double lines running from one end of the crystal to the other, crossing 
each other in the centre and giving the characteristic so-called letter- 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 101 

envelope shape; when they are seen edgewise the octahedral form is 
more marked. These regular forms often commence to break down, so 
that the lines become lost. A number of the crystals may be arranged 
together, either in twos, giving the twin form, or in groups of three, four, 
or more. With these we often see small, more or less regular squares or 
dot-like irregular formations, the so-called amorphous shapes. A number 
of small squares may combine together, giving concretions sometimes of 
large size, which are especially abundant under the microscope when cal- 
cium-oxalate calculi are present. They are often massed together upon 
mucus-threads or foreign substances. Besides these, there are rarer 
forms, consisting of more or less concentrically striated, highly refractive 
discs or barrel shapes, and of variously sized dumb-bells. The latter may 
assume large proportions, and are easily differentiated from the dumb- 
bell forms of uric acid or ammonium urate, by their being colorless. 

The common forms of calcium-oxalate crystals can hardly be mistaken 
for anything else, if it is borne in mind that they are always without color 
and of a moderate refraction. The small discs may be mistaken for red 
blood globules, but are of a considerably higher refraction than the latter. 
Although usually present in acid urine only, they may be found in am- 




x* ?.& **«&*- ^H'^viV?;^ 



Fig. 26. — Granules of Sodium Urate Changing to Globules and Dumb-bells 

(X 500). 

photeric or faintly alkaline urine in small amount. When the reaction 
of an originally acid urine has become alkaline, they gradually dis- 
appear, while triple phosphates commence to develop. Should there 
be any doubt as to their character, they will be found to be insoluble 
in acetic acid, but soluble in hydrochloric acid. 



102 



URINARY ANALYSIS AND DIAGNOSIS. 



When calcium oxalate is present in the urine in large amount, with a 
high specific gravity, 1.024, 1.030, or even 1.040, it often denotes the 
existence of oxaluria. This affection, although very common, is fre- 
quently overlooked. It gives the symptoms of neurasthenia, dyspepsia, 




Fig. 27. — Calcium-oxalate Crystals (X 500). 



melancholia, general malaise, headaches, and ill-defined pains in the 
lumbar region. Those afflicted are usually of sedentary habits and are 
accustomed to live well. In rare cases, especially when concretions of 
considerable size are present, hematuria, often severe and protracted, is 
a pronounced symptom. It may last for months, but its cause can at 
once be ascertained by an examination of the urine. As soon as the pa- 
tient's diet is regulated and he takes considerable outdoor exercise, the 



CRYSTALLINE AND AMORPHOVS SEDIMENTS. 103 

oxalates decrease and the symptoms improve. With such cases inflam- 
mation of the pelvis of the kidney, and sometimes also of the kidney 
proper, though, as a rule, mild in character, is of common occurrence. 

4. Cystin. — Cystin is a comparatively rare sediment, but may pro- 
duce concretions in the bladder. It consists (see Fig. 28) of hexagonal, 
colorless plates of moderate sizes, of high refraction, which, in side view, 
present one perfect facet and two imperfect neighboring facets. A num- 
ber of plates may lie together, one upon another, or they may form more 
or less regular masses. It is readily soluble in ammonia, one of the feat- 
ures distinguishing it from uric acid. Cystin contains considerable sul- 
phur as a constituent. 

Cystin seems to occur in all members of certain families instead of 
uric acid; in such families it appears to replace uric acid, and in them 
cystin calculi are not rare. 

5. Creatinin. — Creatinin, normally present in the urine in very small 
amount, is found under the microscope in rare instances only. It consists 







Fig. 28.— Cystin Crystals (X 500). 



(see Fig. 29) of colorless prisms or plates, partly lozenge- and partly bar- 
rel-shaped. Frequently there are two, three, or even more plates, one 
within the other, or the plates may conglomerate in groups. Occasion- 
ally, more particularly when the urine has stood for some time, peculiar 
configurations appear in the interior of the plates. 



104 



URINARY ANALYSIS AND DIAGNOSIS. 



Creatinin is found most frequently after prolonged muscular exercise, 
as is seen in athletes during active training. A rare sediment, found in 
the urine of a perfectly healthy athlete, is shown in Fig. 30. This sedi- 
ment contains plates and lozenges of creatinin, the rare crystalline form 




Fig. 29.— Creatinin Crystals (X 500). 




Fig. 30. — Sediment in the Urine of an Athlete ( X 500). 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 105 

of sodium urate, and peculiar formations, consisting partly of fan-shaped 
and partly of angular crystals, from which a varying number of long 
needles are seen to emanate. Some of these crystals resemble rarer forms 
of ammonium urate. 

Clinically, creatinin has been found in cases of severe acute paren- 




Fig. 31.— Hippuric Acid (X 500). 

chymatous nephritis, associated with uremic convulsions, and has also 
been seen in the urine in typhoid fever, pneumonia, and diabetes. 

6. Hippuric Acid. — Hippuric acid, which is present in all normal 
urine, is almost always held in solution, though it may be found in small 
amount after a vegetable diet and after eating certain fruits, such as 
cranberries, plums, and prunes. In the urine of herbivorous animals. 



106 



URINARY ANALYSIS AND DIAGNOSIS. 



especially in horses, it is of common occurrence. It is found in larger 
amount after the administration of benzoic acid or one of the benzoates, 
salicylic acid, cinnamic acid, and oil of bitter almonds. It has also been 
seen occasionally in diabetes. 

It consists (see Fig. 31) of variously sized, colorless prisms and plates, 
often conglomerated into larger or smaller masses. The plates may be 




Fig. 32— Leucin and Tyrosin (X 500). 



thin and extremely long, at times resembling needles. Hippuric acid 
might occasionally be mistaken for some forms of phosphates, but can 
easily be differentiated from them by its insolubility in acetic acid. 

7, 8. Leucin and Tyrosin. — Leucin and tyrosin are rare sediments, 
and usually occur together. They are never seen in normal urine, but 
mostly in severe acute and usually fatal diseases of the liver, such as 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 107 

acute yellow atrophy of the liver, phosphorus-poisoning, and in yellow 
fever. They have also been found in cases of smallpox, scarlet fever, and 
typhoid fever. 

Leucin (see Fig. 32) appears under the microscope in the form of flat, 
yellowish or brown globules of different sizes, with delicate radiating and 
concentric striations. Tyrosin is found in the form of needle-shaped 
crystals, grouped in clusters or sheaves, crossing at various angles. 

Both leucin and tyrosin somewhat resemble fat, the former the fat- 
globules, the latter the needles of fat — so-called margaric acid — but differ 
from fat by being insoluble in ether. 

9. Calcium Sulphate. — Calcium sulphate (see Fig. 33) occurs in 




Fig. 33. — Calcium-sulphate Crystals (X 500). 

urine in a small number of cases only, the specific gravity of the urine 
being, as a rule, high. It consists of thin, colorless prisms or needles, 
either single, in groups, or in rosettes, resembling crystalline calcium 
phosphate, but more regular. Its clinical significance is not known. 



B. ALKALINE SEDIMENTS. 



1. Triple Phosphates. — Triple phosphates, the combined ammonio- 
magnesian phosphates, may be divided into complete and incomplete. 
They may be found under the microscope in small numbers in urines 
which still give a faintly acid reaction, but invariably denote a change to 



108 



URINARY ANALYSIS AND DIAGNOSIS. 



alkalinity. When present in large numbers, the urine is always alkaline. 
These phosphates are frequently secondary formations, not being seen 
when the urine is freshly voided, but being found in varying numbers a 
few hours later. They may be seen to develop while the urine is exam- 




Fig. 34. — Complete Triple Phosphates (X 500). 



ined under the microscope. As all urates are colored to a greater or less 
degree, all phosphates are invariably colorless. 

Complete triple phosphates (see Fig. 34) are colorless, triangular 
prisms or rhomboidal crystals, highly refractive, with bevelled ends — the 
so-called coffin-lid shapes. They vary greatly in size and shape, the latter 
being different when the crystals are seen in front, side, or top view. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 109 

Some of the smaller ones can hardly be differentiated from calcium oxa- 
late crystals. 

Incomplete triple phosphates (see Fig. 35) are seen in many forms and 
sizes. It seems that these crystals are in part not yet fully developed 
(especially the smaller varieties, which may in time grow and become 




Fig. 35. — Ixcomplete Triple Phosphates (X 500). 



complete), and in part have become broken down from previously com- 
plete forms. All the different transitions can be seen in the same speci- 
men when it is studied on two or three successive days, which can easily 
be done by simply adding a drop of glycerin to the urine upon the slide. 
The incomplete forms represent irregular plates, either without any dis- 



110 URINARY ANALYSIS AND DIAGNOSIS. 

tinct marks or with irregular lines, the result of the transformation of the 
complete crystals. The crystals may be broken down in the centre, or 
there may be peculiar cross-like formations, or even irregular star-shaped 
crystals, which can be likened to a fern leaf. 

Triple phosphates may be found in varying numbers in normal urine 
after a vegetable diet. Their amount is increased in chronic inflamma- 
tory conditions of all kinds, in rheumatic processes, in inflammation of 
the bones, and in diseases of the nerve-centres. They are especially abun- 
dant in cases of chronic cystitis, where an alkaline putrefaction of the 
urine takes place in the bladder, and may be precipitated in large, flaky 
deposits, the urine having a pronounced ammoniacal odor. 

2. Simple Phosphates. — Simple phosphates, or calcium phosphates, 

°o o.t > e °oo, go o. ' o.'- o '''.>.- '•' 



\-° '••••• i: -°-::*J %*.".• *:* ...o: 

o o • . • o o o g # t a 
n O o Q o O oo°.<> ° o • . "f^ o o , o 

o o . ° o oo°o ° o > %%%<£ % I ; - '•! • \\ •» , , , 

o '"oo _ „ 



°ovv7^-.-;v 



O' " 
O- 



•• . .' V 





. 






.'0 

(3 




Fig. 36. — Amorphous Simple Phosphates (X 500). 

are of two distinct varieties: first, amorphous; and second, star-shaped 
or stellate. 

Amorphous simple phosphates (see Fig. 36) appear in the form of 
colorless globules or granules, of a moderate refraction, either single or 
clustered together in variously sized groups, but never in a moss-like 
arrangement, as the sodium urate. These phosphates are abundantly 
found after a milk diet, as well as after drinking different alkaline min- 
eral waters. 

Star-shaped or stellate simple phosphates, although of less frequent 
occurrence than the other variety, are by no means rare, and are often 
found in conjunction with the triple phosphates. They consist (see Fig. 
37) either of slender, colorless rods or of pointed spicules of various sizes, 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. Ill 

at times larger and smaller ones being found together. Although they 
may be found single, their characteristic grouping is in the form of stars 
or rosettes, more or less complete. The spicules, of which the rosettes 
are composed, are united in the centre of the rosette, while each spicule 




Fig. 37. — Star-shaped Simple Phosphates (X 500). 



may have a uniform diameter or be broadened at the periphery and nar- 
rowed in the centre. 

Much has been written about the significance of the phosphates in the 
urine, and great stress has been laid upon their continual increase or 
diminution, the latter being said to be of constant occurrence in cases of 
nephritis. It is an undeniable fact that the phosphates are diminished 



112 



URINARY ANALYSIS AND DIAGNOSIS. 



in severe and usually advanced cases of nephritis, but not more so than 
the other salts, there being a pronounced decrease of all salts in such 
cases. 

In rare cases there is a continual increase of the phosphates in the 
urine, without any apparent cause. Such cases have been designated by 
the term phosphaturia, and they may give similar symptoms to those of 
oxaluria. The phosphates precipitating in the urine being frequently 







Fig. 38. — Ammonium Urate ( X 500). 



secondary formations, such a diagnosis must only be made when their 
amount is found to be greatly increased immediately after the urine is 
voided, and the presence of inflammatory conditions of any kind in the 
body can be excluded. A change of diet will often rectify this trouble in 
a short time. All phosphates are easily soluble in acetic acid, which will 
quickly clear up any doubts as to their character. 

3. Ammonium Urate. — Ammonium urate is a common sediment in 
alkaline urine, especially in connection with triple and simple phosphates, 
and is seen in fresh urine only when it is passed in an alkaline condition. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 113 

It is the result of alkaline decomposition. It appears (see Fig. 38) in the 
form of brown globules of various shapes and sizes, usually exhibiting 
pronounced concentric and radiating striatums. The globules may ap- 
pear singly or in clusters, sometimes forming large, coalesced masses. 
They are either smooth or provided with thorny, sometimes branching 

e e & q o . 




Fig. 39. — Acid Sediment in Fermentation and in Transition to Alkaline (X 500). 

U, Uric-acid plates ; UN, uric-acid needles ; US, sodium urate in transition to globules 

and dumb-bells; UA, ammonium urate; O, calcium oxalate; C, conidia; M, mycelia. 



and curved offshoots — the so-called thorn-apple shapes. The offshoots 
vary greatly in size and number, there being either one or many upon a 
single globule. Not infrequently the globules, especially the smaller ones, 
conglomerate so as to form concretions, sometimes of large size, and this 
may also be the case when mucus-threads or foreign substances, such as 

8 



114 URINARY ANALYSIS AND DIAGNOSIS. 

cotton or linen fibres, are present. Upon the addition of hydrochloric 
acid the globules of ammonium urate disappear and small rhombic crys- 
tals of uric acid are formed. Ammonium urate is soluble in alkalies, by 
the addition of which an odor of ammonia is evolved. 

The alkaline change, which may take place in an originally acid urine, 
is illustrated in Fig. 39. When the urine was voided it contained nothing 
but a large number of uric-acid crystals of different forms, both plates 
and needles, some groups of sodium urate, and crystals of calcium oxa- 
late. After about twelve hours fermentative changes commenced to ap- 
pear, and fungi, in the form of conidia and mycelia, developed. The 
sodium-urate granules were now found to have partly changed into small 
globules and dumb-bells, possibly the first formed ammonium urate. 



qO ofli "a- 



o.-'-'J *!! 



Fig. 40. — Calcium Carbonate and Magnesium Phosphate (X 500). 

This change gradually continued until larger globules of ammonium 
urate, as well as more irregular forms, had developed. Triple phosphates 
were not seen in this specimen. 

4. Calcium Carbonate. — Calcium carbonate is a not very uncom- 
mon alkaline sediment, occurring either alone or in combination with 
the phosphates. It is usually found (see Fig. 40) in the form of amor- 
phous granules and globules of different sizes, though mostly larger than 
the globules of amorphous simple phosphates; they are seen either singly 
or in groups of varying sizes, and are of very high refraction. Occa- 
sionally dumb-bell forms are also present, and very rarely small delicate 
prisms. By adding an acid, such as acetic acid, effervescence is pro- 
duced, which also occurs in the presence of ammonium carbonate, though 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 115 

this is always held in solution and never seen under the microscope. Cal- 
cium carbonate is the most common sediment in herbivorous animals, 
and the turbidity of their urine is due to its presence. 

This salt appears mainly in inflammatory and carious processes of the 
bony system, such as osteitis, osteomyelitis, osteomalacia, and rhachitis. 
It may also be found in diabetes and phthisis. After drinking certain 
mineral waters in large quantities it may be seen in the urine. 

5. Magnesium Phosphate. — Magnesium phosphate (Fig. 40) is an 
extremely rare sediment, producing colorless, highly refractive, elongated, 
quadrilateral prisms, sometimes resembling the small plates of incom- 
plete triple phosphates. It is observed in the urine after the internal use 
of the fixed alkali-carbonates, such as are held in solution in many min- 
eral waters, and may be found with calcium carbonate. It is readily 
soluble in acetic acid. 



II. OTHER UNORGANIZED SEDIMENTS. 

Fat. — Fat, in the form of globules and granules, is of common oc- 
currence in the urine, but care must be taken not to confound it with 




Fig. 41. — Fat-globules and Margaric-acid Needles (X 500). 



extraneous fat-globules, which in many cases are larger, more irregular, 
and of a more yellowish color. If fat is not present in too large quan- 
tities, the microscopical appearance of the urine is not changed, but if it 
exists in large amount, as, for instance, in the rare cases of chyluria, in 
connection with considerable albumin, the urine is turbid or milky when 



116 URINARY ANALYSIS AND DIAGNOSIS. 

voided, and, after standing, a peculiar creamy layer appears at the top 
of the urine. When fat-globules are voided in such large quantities as to 
be seen with the naked eye, and albumin is either entirely absent or 
present in small amount only, the diagnosis lipuria is justified; these 
cases are, however, just as rare as those of chyluria. The addition of a 
few drops of ether clears up the urine to a certain degree. 

Fat-globules and -granules vary considerably in size (see Fig. 41). 
When the larger globules are found, needles of margaric acid may also be 
present; these are long, slender formations, in which a double contour 
can be seen only in rare instances. They he between the globules, as well 
as within them in some cases, and may also appear to emanate directly 
from them. Fat-globules have a high refraction and usually a rather 
dark contour. 

Leaving out of consideration the rare cases of chyluria and pronounced 
lipuria, the latter of which has been observed in healthy individuals tem- 
porarily after a highly fatty diet, as well as in pregnant women and in cases 
of phosphorus-poisoning, the appearance of a small or moderate number 
of small fat-globules and -granules, either singly or in variously sized 
groups, is seen in all cases in which a chronic inflammation, even of mild 
character, exists somewhere in the geni to-urinary tract. These globules 
are not only found lying free throughout the different fields, but in vary- 
ing numbers within the epithelia and pus-corpuscles, being undoubtedly 
secondary products of the protoplasm. The globules may make their 
appearance in small numbers a few weeks after the commencement of 
the inflammation, but are found in greater quantity only in chronic cases ; 
the more numerous the globules, the more pronounced the inflammation. 
At first, one or two glistening globules of very small size are seen in the 
granular protoplasm, which condition becomes more and more pro- 
nounced, until the fatty degeneration, in severe cases, attacks the whole 
of the epithelium, occasionally changing its appearance completely. 

Such fat-globules are, therefore, found not only in chronic cases of 
nephritis and pyelitis, but also in cystitis, prostatitis, urethritis, and vag- 
initis. In the different varieties of nephritis their numbers vary greatly. 
When present in small or moderate numbers only, no other diagnosis 
than that of a chronic inflammation is justifiable; but if very abundant, 
either with or without the presence of fatty casts, a diagnosis of fatty de- 
generation can be made. 

Cholesterin.- — Cholesterin, a normal ingredient of bile, is occasion- 
ally found in the urine. It consists (see Fig. 42) of colorless, thin, irregu- 
lar rhomboidal plates, frequently broken in different parts and of greatly 
varying sizes. It easily dissolves in ether, and takes on a reddish or vio- 
let color if treated with iodine and a drop of a sulphuric-acid solution. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 117 

Cholesterin has been found in a few cases of chronic cystitis, in rare 
cases of chronic parenchymatous nephritis with fatty degeneration, and 
in chvluria. Its exact significance is unknown. 




Fig. 42. — Cholesterin Crystals ( X 400). 







M 

Fig. 43. — ILematoidin Crystals (X 500). 

Haematoidin. — Harnatoidin crystals seem to be the result of extrav- 
asated blood, if retained within the tissues. They appear in the urine 
(see Fig. 43) in the form of small, irregular plates, as well as needle- 



118 URINARY ANALYSIS AND DIAGNOSIS. 

shaped, sometimes stellate, crystals of a reddish-brown or, rather, rust- 
brown color. The needle-shaped crystals vary considerably in size, and 
may be found either singly or in conglomerations of peculiar forms. Not 
only may the needles be arranged so as to form bunches resembling the 
bristles of a brush, but an irregular mass may be surrounded by a large 
number of needles, sometimes giving a crab-like appearance. The larger 
formations are rare, while the smaller are comparatively common, not 
only lying free, but also in the interior of pus corpuscles and epithelia. 
Their presence always denotes a hemorrhage which has taken place at 
some previous time, and they may, therefore, be found in a variety of 
different lesions. 

Besides hsematoidin, it is claimed that bilirubin may be found under 
the microscope, closely resembling the crystals of hsematoidin, and seen 
in both plate and needle form. They are usually larger and more irregu- 
lar than the former, and their relationship is still undecided. 

Indigo. — All normal urine contains a small amount of indican, and 
the indigo occasionally found in the urine is, as a rule, a secondary prod- 






' JAB. * * fft 






Jk 



/ IL 



i' 



w § w ff> w m 

Fig. 44. — Indigo Crystals (X 500). 

uct of oxidation, often seen when putrefactive changes have developed. 
In rare cases the urine has a bluish color when voided, the indigo having 
been formed in the body; this is seen in pathological conditions only. 

Indigo (see Fig. 44) is seen in the form of blue rhomboidal crystals of 
small size, or irregular masses, as well as in needles and thin plates. Al- 
though it was formerly always considered to have a pathological signifi- 
cance, it is now known to be present in perfectly normal conditions. It 
is not uncommon to see indigo under the microscope in small amount as 
extraneous matter from the underwear, and this cannot, in most cases, 
be distinguished from that formed in the urine. 



CRYSTALLINE AND AMORPHOUS SEDIMENTS. 119 

Melanin. — Another coloring matter which at times is seen in the 
urine is melanin, appearing as dark brown or perfectly black, irregular 
granules or masses of small size. It has been found in melanotic tumors, 
such as sarcoma and cancer, as well as in broken-down constitutions 
due to various troubles, and cannot be said to have any special sig- 
nificance. 

After intra- vesical injections of silver salts, such as argyrol, the 
urine may contain black granules and masses of varying sizes, which 
microscopically cannot be differentiated from melanin. These gran- 
ules may be found in smaller or larger numbers, both in free groups, 
irregularly scattered, and upon pus corpuscles and epithelia. 



URINARY CONCRETIONS. 

Quite frequently concretions may form in the urinary passages and 
be found in the urine. When very small, these concretions are called 
gravel; when large, stones or calculi. The former can be passed in large 
amount with little or no pain; the latter cause great suffering and the 
condition may require surgical interference. Concretions are formed 
either in the kidney, pelvis of kidney, or bladder, and most frequently 
consist of uric acid, urates, calcium oxalate, or phosphates. Besides 
these, concretions of cystin and calcium carbonate, as well as indigo and 
xanthin, may be found. 

Concretions may consist of one ingredient only, or of two or more in 
alternate layers. The majority of concretions have a central portion or 
nucleus and a peripheral portion or body. The nucleus varies in size and 
composition. It may consist of the same material as the body, though, 
as a rule, some organic product, such as a blood clot or mucus-thread, will 
form the nucleus, around which the body of the calculus forms. In rare 
cases, foreign bodies introduced into the bladder from outside become the 
nuclei of stones. 

The most common are the uric-acid concretions, which may be passed 
in large amount in the form of gravel, but often attain a large size. They 
compose from seventy to eighty per cent of all concretions, and are 
formed either of uric acid alone or combined with the urates; are hard, 
and have a yellowish-brown or reddish-brown color. Calcium-oxalate 
concretions have a grayish or dark color, and may be either small, round, 
and smooth — called hemp-seed calculi — or large, rough masses — the mul- 
berry calculi. Sometimes the nucleus of these concretions consists of 
uric acid. Phosphatic concretions are usually formed of mixed triple 
phosphates and calcium phosphates. They are mostly of large size and 
have a grayish- white color. Other concretions are of rare occurrence. 



120 URINARY ANALYSIS AND DIAGNOSIS. 

In many cases their nature can easily be determined by placing a minute 
particle in a drop of glycerin under the microscope. 

Although the presence of concretions, even when very minute, can 
almost invariably be determined by microscopical examination of the 
urine, a number of examinations must not infrequently be made before 
the diagnosis becomes positive. The first urine examined may contain a 
small number of salts only, or these may be entirely absent under the 
microscope, though subsequent examinations will show them in large 
amount and clear up any doubt. In all such cases inflammations or 
hemorrhages from the kidney, pelvis of kidney, or bladder will sooner or 
later develop. 

For a more detailed analysis, the concretions should be powdered and 
subjected to a red heat upon platinum foil. If the odor of hydrocyanic 
acid is given off, the concretion contains either uric acid or xanthin, the 
latter of very rare occurrence. Uric acid gives the characteristic murex- 
ide test; xanthin does not. If considerable residue of ash is left, which 
when heated to a high temperature melts to a white mass, it contains 
phosphates ; phosphatic concretions are soluble in hydrochloric acid with- 
out effervescence. If the powder first blackens upon heating, but upon 
further heating leaves considerable white ash, which dissolves in hydro- 
chloric acid with effervescence, it contains calcium oxalate; if this solu- 
tion is neutralized with ammonia, and oxalic acid is added, characteristic 
envelope-shaped crystals, which are readily recognized under the micro- 
scope, are precipitated. If the powder upon burning emits an odor of 
sulphurous acid and burns with a bluish flame, it contains cystin; when 
ammonia is added to the powder it dissolves, and upon evaporation crys- 
tallizes in hexagonal plates easily diagnosed by the microscope. Calcium- 
carbonate concretions dissolve in hydrochloric acid with effervescence. 
In order to ascertain if a calculus consists of more than one ingre- 
dient, it is best to section it and examine the powder from each layer sep- 
arately. 



CHAPTER X. 

BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 
I. BLOOD-CORPUSCLES. 

Red blood-corpuscles or red blood-cells are of common occurrence in 
the urine ; they may be derived from any portion of the genito-urinary 
tract. When present in small numbers, the urine is either not changed 
in color or it is cloudy, turbid or smoky; but when they occur in large 
numbers, the urine has a reddish hue and may be of a dark red or 
deep brown color, the condition being then known as hcematuria. Dur- 
ing the period of menstruation red blood corpuscles occur normally 
in the urine of females, but with this exception their appearance 
invariably indicates some abnormal condition. 

Red blood-corpuscles, as found in the urine, vary considerably in ap- 
pearance, shape, and size (see Fig. 45). In fresh urine they are discoid 
bodies of a yellowish hue and frequently crenated, but after a few hours 
only may have entirely lost their haemoglobin and are then practically 
colorless. This change takes place more quickly in alkaline than in acid 
urine, and also depends upon the degree of concentration of the urine. 
As long as the blood-corpuscles contain considerable haemoglobin, they 
have a yellowish color; as soon as they commence to lose their coloring 
matter, a double contour can usually be seen, the interior being in most 
cases apparently structureless. This is the condition in which they are 
most frequently found. 

When they are present in large numbers, they are found both singly 
and conglomerated in variously sized masses, and the so-called thorn- 
apple shapes are often seen. When they lie edgewise they appear biscuit- 
shaped, and may be found in small masses like rolls of coin ; the latter is 
comparatively rare in urine. As a rule they are neither granular nor nu- 
cleated, and can thus easily be distinguished from pus-corpuscles, even if 
the double contour is not well marked. In acid urine, however, after it 
has been standing a few days, a small number may appear granular 
and quite irregular. 

Unless blood-corpuscles are present in very small numbers only, 
every urine containing them will also contain an appreciable amount of 
albumin. In severe cases of haematuria the amount of albumin may 
reach one-half of one per cent or more, and still the kidneys be perfectly 

121 



122 



URINARY ANALYSIS AND DIAGNOSIS. 



normal, the blood coming perhaps from the bladder, the urethra, the 
prostate gland or the seminal vesicles. 

When the urine is of a low specific gravity, the red blood-corpuscles 
frequently swell and become hydropic. In such cases they are large, pale, 
double-contoured bodies, and are called "ghosts." In an active hemor- 
rhage, besides the corpuscles described, small globules are frequently 






Fig. 45. — Blood-corpuscles (X 500). 



seen, which are sometimes less than half the size of the regular corpuscles, 
but perfectly characteristic. These are of recent formation, are im- 
mature red blood cells, and may be called ha3matoblasts. 

Whenever a large number of red blood-corpuscles is present in the 
urine, a small number of white blood-corpuscles or leucocytes is invariably 
seen. They vary in amount, but average one of the latter to five hun- 
dred or six hundred of the former. Leucocytes cannot be distinguished 
from pus-corpuscles. They are usually found in the form of globular, 
granular bodies, which may or may not show a nucleus, though they 
can easily change their form on account of the contractility of their 
protoplasm. When a hemorrhage exists and these corpuscles are seen 
in small numbers only, they should not be mistaken for pus-corpuscles. 

In an active hemorrhage we frequently notice, besides blood-corpus- 
cles, fibrin, as well as clots of blood (see Fig. 46). 

Fibrin appears either in the form of thin, pale, colorless strings, or 
larger, more or less reddish or brown masses, frequently giving off smaller 
branches. It always consists of wavy bands, of a higher refraction at the 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 123 

periphery than in the centre, and of a characteristic appearance. When 
Large, the masses can easily be seen with the naked eye. In rare cases, 
such as severe hemorrhages due to tumors or parasites, they may attain 
enormous sizes. Not infrequently they resemble cast-like structures 
or even form distinct casts. 

Blood-clots consist of irregular, rust-brown or dark masses, varying 
in size, which are composed of disintegrated blood-corpuscles; they 
may be so dense that their structure cannot be made out, and they 
must be diagnosed from their color. 

When blood-corpuscles, even in small numbers, are present in the 
urine, it is absolutely essential to discover their source. This can only 
be determined by the nature of the epithelia in the urine. As long as 
the hemorrhage is mild or of moderate severity only, epithelia can al- 




Fig. 46. — Fibrin and Blood-clot ( X 500). 

ways be found without any difficulty; but in the worst cases of hsema- 
turia, where many fields of the microscope may be crowded with 
blood-corpuscles, it is at times quite difficult to find epithelia. In 
these cases many drops of urine must sometimes be examined before 
the source of the hemorrhage can be positively determined. Some 
authors advise the removal of the blood from the sediment by the 
addition of a large amount of lukewarm water and a few drops of 
dilute acetic acid, stirring thoroughly and allowing to settle. 
This process undoubtedly changes many of the other elements 



124 URINARY ANALYSIS AND DIAGNOSIS. 

present in the sediment, and it is best not to use it unless absolutely 
necessary. A much better plan is to dilute a drop of urine upon a 
slide with a drop of chemically pure glycerin; this causes some of the 
masses of the red blood corpuscles to become separated and paler, 
so that the search for epithelia is liable to be more successful. 

The color, reaction, and specific gravity of the urine can never 
afford any positive clew as to the source of the blood, and the nature 
of the haematuria will only occasionally help in clearing up the case. 
In haematuria of urethral origin, due either to inflammations or trau- 
matic conditions, the blood oozes from the urethra between the acts of 
micturition or may be squeezed out. In such cases, as well as in in- 
flammations of the prostate gland or seminal vesicles, the first portion 
of urine voided is liable to contain more blood than the last, which 
may even be practically free from blood. In hemorrhage from the 
bladder, the blood is apt to be more abundant toward the end of mic- 
turition, while in hemorrhage from the upper urinary tract the blood is 
liable to be evenly distributed, so that when the urine is voided into 
two glasses, both will contain an equal amount of blood. Again, ir- 
regular blood clots, sometimes of large dimensions, are more frequently 
present in vesical haematuria, though occasionally fair-sized clots 
may be seen in hemorrhage from the upper urinary tract. 

The pathological conditions in which blood-corpuscles are found are 
numerous. They are present in small or moderate numbers in every 
acute inflammation, whether of mild or severe character, and even in 
simple irritations and congestion. They will be found in a prostatitis 
as well as in a nephritis; also in pyelitis, ureteritis, cystitis, urethritis 
and spermato-cystitis. The presence in the urine of an abnormally 
large amount of salts may be sufficient to set up an irritation of the 
kidney or pelvis of the kidney with the appearance of blood-corpuscles. 

Hemorrhages from the genito-urinary organs are of comparatively 
frequent occurrence and due to many causes. Perhaps among the 
most common of these cases are hemorrhages from the pelvis of the 
kidney, often due to gravel or calculi. Severe inflammations, ab- 
scesses, ulcers, tumors, stricture of the urethra, or traumata of different 
kinds, as well as parasites, will cause them. In tuberculosis of any 
part of the urinary tract, as well as of the prostate gland and seminal 
vesicles, haematuria is a common symptom; in this condition the at- 
tacks of hemorrhage are frequently intermittent, although they may 
continue over a long period. A little care exercised in discovering 
all the features present in the urine will in most cases lead to a posi- 
tive diagnosis of the source of the haematuria. 

Hemorrhage from the kidney itself occurs frequently enough and 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 125 

may be due to numerous causes. It may be found in simple renal 
congestion, as well as in acute and chronic nephritis, in abscess, tuber- 
culosis, concretions or calculi, neoplasms, especially malignant tu- 
mors, different degenerations, also in embolism of the renal artery and 
thrombosis of the renal vein. Renal hematuria may be present in the 
malignant forms of the acute infectious diseases, such as scarlatina, 
variola, yellow fever, typhus and relapsing fevers, Asiatic cholera, in 
typhoid fever, malaria and other conditions; also in blood diseases, 
such as pernicious anemia and the leukaemias, furthermore in purpura 
haemophilia and scurvy. It may be quite pronounced in cases of 
acute nephritis due to poisoning with different drugs such as carbolic 
acid, cantharides and turpentine, and has been observed during the 
administration of urotropin and other drugs. The presence of para- 
sites, such as the filaria sanguinis hominis, distoma haematobium and 
echinococcus may cause it, and it may also be due to traumatism. 

An idiopathic form of renal haematuria has been described, also 
called essential hematuria, in which the hemorrhage occurs without 
apparent cause. Some of these cases are probably angioneurotic ; not 
infrequently a dilatation of the renal blood-vessels, that is a telean- 
giectasis is here present, and sometimes a true angioma. The term 
renal haemophilia has also been applied to these cases, and the haemor- 
rhage is usually intermittent. 

II. PUS-CORPUSCLES. 

Whenever pus-corpuscles are present in the urine, even in small 
numbers, an abnormal condition exists somewhere in the genito-urinary 
tract. If they are very scanty, this condition is not necessarily an 
inflammation, though there is undoubtedly an irritation in some por- 
tion of the tract. As soon as they are found in at least moderate 
numbers, the diagnosis of an inflammation can at once be made, which 
is the more pronounced the greater the number of pus-corpuscles; 
when they are very numerous we may even be justified in diagnosing 
suppuration, though not without other features. 

Urine containing pus-corpuscles in small numbers may appear per- 
fectly normal to the naked eye, but the greater their number the more 
turbid it becomes, and in urine in which they are abundant a heavy, 
grayish-white sediment will sink to the bottom in the course of a few 
hours. In such cases the term pyuria might be properly used. Every 
urine in which pus-corpuscles are present in any appreciable number 
contains albumin, no matter from what organ they are derived, and 
the larger the number of pus-corpuscles the greater the amount of 
albumin. 



126 



URINARY ANALYSIS AND DIAGNOSIS. 



The term " pus-corpuscles " is really a misleading one, since the 
presence of these cells does not necessarily signifj^ the presence of true 
pus; they are found in the urine in every inflammatory condition, 
even in the mildest, though in mild cases they are seen in small num- 
bers only. The greatest numbers of so-called pus-corpuscles are emi- 
grated white blood-corpuscles, hence the two terms of " pus-corpuscles n 
and " leucocytes" are frequently used synonymously. All of these 
corpuscles, however, are by no means derived from the blood-vessels 
through emigration; some are derived from lymph-vessels or lymph- 
channels, still others from the connective-tissue cells through prolifera- 




Fig. 47. — Pus-corpuscles (X 500). 
F, Pus-corpuscles with fat-globules; C, ciliated pus-corpuscles; H, pus-corpuscles with 

haematoidin crystals. 

tions and new-formation, and some may even be derived from the 
epithelia through proliferative changes of their nuclei. The so-called 
pus-corpuscle therefore is a cell due either to emigration or to pro- 
liferation as the result of some irritation and stimulation. As long 
as such a corpuscle remains in connection with the tissues, it is known 
as an inflammatory corpuscle, but as soon as it leaves the tissues and 
is present in an excretion, such as the urine, it is called a pus-corpuscle. 
When these cells are present in large numbers in the tissues, and, when 
with an excessive emigration of leucocytes there is also a destruction 
of tissue elements, true pus is formed. In such cases pus-corpuscles 
are very abundant in the urine, and the term pyuria is justified. 

The presence of so-called pus-corpuscles in urine therefore simply 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 



127 



signifies the presence of some abnormal condition somewhere in the 
geni to-urinary tract, which may be a mere irritation or mild inflamma- 
tion, a severer inflammation, a suppurative or even an ulcerative 
process, in accordance with the numbers of these cells as well as in 
accordance with other features giving evidences of the character of 
the pathological lesion. 

Pus-corpuscles in urine appear mostly as small, round, granular 
bodies, perhaps twice the size of normal red blood-corpuscles, in 
which one or more nuclei may or may not be seen. In freshly voided 
urine pus cells not infrequently exhibit active amoeboid changes, assum- 
ing a variety of irregular forms (see Fig. 47). 

In dilute as well as in highly alkaline urine the pus-corpuscles swell 
and assume a large, globular shape, becoming hydropic. In these a 
central nucleus will be observed, while the granulations around the 
peripheral portions become pale or almost entirely disappear. In 
some cases the nucleus breaks up into a number of small globules, 




Fig. 48. — Pus-Corpuscles Showing Various Changes ( X 500) . 

Individual corpuscles enlarged, swollen, hydropic, nuclei degenerated; masses found 

in ammoniacal decomposition. 



which may remain in the centre of the cell or be pushed toward its 
periphery. The granules may disappear completely so that the entire 
cell appears like a structureless body, or the granules are still seen 
along the periphery of the cell. In ammoniacal urines, as seen in 
chronic cystitis, the pus-corpuscles, when present in large numbers, 
burst and coalesce, producing a sticky mass, which can be transferred 
to the slide only in jelly-like lumps (see Fig. 48). In such cases a 
large amount of mucus is always present, and it may become almost 
impossible to differentiate the pus-corpuscles from mucus-corpuscles. 



128 URINARY ANALYSIS AND DIAGNOSIS. 

The apparent presence or absence of nuclei in the pus-corpuscles de- 
pends entirely upon the amount of granulation; in coarsely granular 
corpuscles they are invisible, but become well marked when the granu- 
lation is fine. Not infrequently varying numbers of small, glistening 
fat-globules and granules appear in the pus-corpuscles, and this fatty 
change may be so pronounced that almost the entire granulation is 
altered. Such a pronounced change always denotes a chronicity of the 
inflammation, although the fat-globules may commence to appear a 
few weeks after the beginning of the inflammation, when the process 
cannot as yet be called strictly chronic. In perfectly acute inflamma- 
tions, however, they are never found, except in some intoxications, 
such as poisoning with phosphorus. 

Sometimes pus-corpuscles are seen which contain delicate, rust- 
brown crystals of hsematoidin, in both needle and plate form. This is 
more especially the case in those derived from epithelia of the pelves 
of the kidneys and the uriniferous tubules of the kidneys, and denotes 
a previous hemorrhage. In recent hemorrhages the pus-corpuscles 
may have a uniform yellow color, due to the imbibition of the coloring 
matter of the blood. A similar diffuse yellow color of the pus-corpus- 
cles is seen when bile is present in the urine, and in pronounced cases 
of choluria the color of the pus-corpuscles may be yellowish-brown or 
greenish-yellow. In cases of chronic catarrhal cystitis, dark brown 
pigment granules may sometimes be found in the pus-corpuscles. Oc- 
casionally pus-corpuscles which have delicate hairlike prolongations — 
cilia — are seen. These arise from the ciliated columnar epithelia of 
the uterus, and when present justify the diagnosis of an endometritis. 
Care must be taken not to mistake bacteria adhering to the surface 
of the pus-corpuscles for cilia. 

Pus-corpuscles may be derived from any portion of the genito- 
urinary tract, and their source can only be determined by the nature of 
the epithelia present in the urine. Being invariably found in every in- 
flammation, the mildest as well as the most pronounced, they are 
among the most common of all the elements found in the urine. To 
diagnose an inflammation of the kidney, it is by no means necessary 
to find casts, since a number of kidney lesions, sometimes quite severe 
in character, exist without the presence of casts. Irritation from a large 
number of salts, which is common in the pelvis of the kidney, is suffi- 
cient to show a small number of pus-corpuscles. Although highly 
alkaline urine frequently accompanies an inflammation of the bladder, 
no positive conclusion can be arrived at without the characteristic 
epithelia. Again, in the urine of a female a large number of pus- 
corpuscles may be present without any other trouble than a vaginitis, 



BLOOD-CORPUSCLES AND PUS-CORPUSCLES. 129 

though this may be sufficient for an appreciable amount of albumin to 
appear. The same may be said of prostatitis and urethritis. Any 
doubt as to the origin of the pus-corpuscles will at once be dispelled 
by finding the characteristic epithelia in the urine. 

From what has been said no difficulty should be encountered in 
diagnosing pus-corpuscles when they are present, even in small num- 
bers, though it must be remembered that they are bound to vary in 
size and appearance in different cases, and to a small degree even in 
the same case. Their differentiation from the smallest epithelia, 
especially the kidney epithelia, when the latter are present in small 
numbers only, may not always be easy. Kidney epithelia, however, 
are distinctly larger than the largest pus-corpuscles in the same case, 
provided that these corpuscles have not become hydropic. When 
they are hydropic they may become quite large, but then are always 
pale and finely granular or have lost their granules more or less com- 
pletely. Kidney epithelia, on the other hand, are distinctly granu- 
lated, and, as a rule, have a fairly large, distinct, usually centrally 
located nucleus. 

When an ammoniacal decomposition has set in, which often enough 
occurs in cases of chronic cystitis, the pus-corpuscles may have become 
more or less completely changed, and converted into a gelatinous or 
jelly-like mass, in which characteristic corpuscles cannot be recognized 
any more. In such cases it may be of advantage to apply certain 
tests for a positive recognition of their presence. A simple test is 
that of Vitali: Acidify the urine with acetic acid and filter; treat the 
contents of the filter with a few drops of tincture of guaiac, when a deep 
blue color appears in the presence of pus. If it is impossible to filter 
the urine on account of its thick, ropy character, place a small amount 
of the urine in a test tube, and allow a few drops of tincture of guaiac 
to flow upon the surface. If pus is present a distinct blue line of con- 
tact will be observed. 

The knowledge of the fact that in ammoniacal urine pus becomes 
transformed into a gelatinous mass, due to the action of ammonium 
carbonate, has been utilized by Donne, whose test for the presence of 
pus in a suspected urine consists in treating the urine or its sediment 
with a few drops of a concentrated solution of sodium or potassium 
hydrate, when, in the presence of pus in small amounts the liquid 
becomes mucilaginous and ropy, in larger amounts converted into a 
gelatinous, mucus-like mass, which adheres to the bottom and sides 
of the test tube. 

The so-called iodine-reaction of pus corpuscles sometimes gives 
positive results but as a rule only in intense pathological conditions. 



130 URINARY ANALYSIS AND DIAGNOSIS. 

A drop of the urine-sediment upon a slide is mixed with a drop of an 
iodine-iodide of potash solution such as Lugol's solution. Owing to 
the presence of glycogen, the pus-corpuscles after such treatment may- 
stain a dark mahogany brown, while the epithelia, which may resemble 
them, assume a light yellow color. This test when positive is quite 
characteristic, but often enough, especially in simple inflammations, 
it cannot be obtained. 



CHAPTER XI. 

EPITHELIA. 

With very few exceptions, epithelia present in the urine always de- 
note a pathological process of some kind. Normally the only epithelia 
found in urine are irregular, flat epithelia from the bladder, in small 
numbers, while in urine of females there may be flat epithelia from the 
vagina; the presence of all other epithelia is pathological. Although it 
is claimed to be impossible to diagnose the sources of the different epi- 
thelia in the urine, this is not at all difficult, provided a few general points 
are always borne in mind; and it is only by an accurate knowledge of 
their sources that we are able to obtain a diagnosis of the location of the 
morbid process. Most of the morbid processes occurring along the genito- 
urinary tract are inflammatory in nature, and marked by the presence of 
pus-corpuscles in the urine, and the location of the inflammation is deter- 
mined by the epithelia. 

Before speaking of the nature of the different epithelia found in the 
urine, it is necessary to have an idea of the general characters of the 
epithelia occurring in the body. These are of three kinds: First, flat 
or squamous; second, cuboidal; and third, columnar or cylindrical. Flat 
epithelia are always more or less irregular in outline, exhibiting a broad 
front surface, while in edge view they are narrower and somew r hat spindle- 
shaped. Cuboidal epithelia have about the same diameter in all direc- 
tions, while columnar epithelia are elongated in one direction. The latter 
may be ciliated, having one or more delicate, hair-like prolongations on 
the outer surface. All epithelia are granular and possess one or more 
nuclei, which, however, need not always be visible and may have dropped 
out, leaving a vacuole. The granulation may be coarse or fine, the flat 
epithelia being frequently more finely granular and paler than the others. 

All epithelia may occur either in a single layer or stratified; that is, 
there may be a number of different layers. Wherever stratified epithelia 
occur and all three varieties are present, the flat variety is seen to com- 
pose the outer or upper layers, the cuboidal the middle layers, and the 
columnar the inner or deepest layer, nearest to the connective tissue. 

In the genito-urinary tract a lining of stratified epithelium is found in 
the pelves of the kidneys, the ureters, bladder, urethra, vagina, and cer- 
vical portion of the uterus, while a simple epithelial lining exists in the 

131 



132 URINARY ANALYSIS AND DIAGNOSIS. 

uriniferous tubules of the kidneys, the prostate gland, seminal vesicles, 
ejaculatory ducts, Bartholinian gland, and mucosa of the uterus. 

It is maintained that the epithelia from different organs, such as the 
bladder, ureters, and pelves of the kidneys, are identical in size and shape. 
By scraping off the epithelia of these organs, this idea appears correct; 
but if the epithelia are examined in situ, we will soon be convinced that 
their sizes vary considerably. The largest epithelia are found in the va- 
gina; the next in size in the bladder; then, in order, those of the cervix 
uteri, urethra, pelves of the kidneys, ureters, and prostate gland; the 
smallest in the uriniferous tubules. It must not be forgotten, however, 
that there are transitional sizes, which are of no value for diagnosis. The 
smallest cuboidal epithelia from the bladder, for instance, may be iden- 
tical with the largest cuboidal epithelia from the pelves of the kidneys, 
but the average size is absolutely different, being considerably smaller in 
the pelves than in the bladder. Again, the caudate and lenticular forms 
of epithelia are far more prevalent in the pelves and calices than in the 
bladder, and are well adapted for a diagnosis. 

All epithelia change to a certain degree in the urine, more especially 
the cuboidal, which are originally angular polyhedral formations; by the 
imbibition of the watery constituent of the urine, they swell and assume 
a more or less regular, even perfectly spherical, form. This change af- 
fects all epithelia alike, and the size of the spheres is sufficient for a diag- 
nosis of their previous location. " 

In the vagina and bladder, where the epithelia are large, the differ- 
ence between the flat, cuboidal, and columnar varieties is naturally most 
marked, while in the pelves, ureters, urethra, and cervical portions of 
the uterus it is not so pronounced. In the prostate gland the simple 
epithelial lining is usually cuboidal, though sometimes columnar, while 
in the ducts of the prostate gland and the seminal vesicles it is columnar 
only. In the ejaculatory ducts, as well as in the mucosa of the uterus, 
ciliated columnar epithelia are present, though in the urine the cilia break 
off easily and may not be seen. In the uriniferous tubules of the kidney 
the simple epithelial lining varies in different portions, being partly flat, 
partly cuboidal, and partly columnar; the flat and cuboidal epithelia can- 
not be distinguished, while the columnar variety is well marked. 

In every urine flat, horny epithelia from the genitals — the prepuce in 
the male, and the clitoris and labia in the female — may be found, and are 
called epidermal scales (see Fig. 49). They have a jagged contour, are of 
a rather high refraction, and do not contain a nucleus, but are frequently 
studded with dirt particles and fat globules. In addition, their granula- 
tion — if any is present at all, which is rarely the case — is extremely pale, 
and they appear more or less shrivelled. They vary in size and shape con- 



EPITHELIA 



133 



siderably, and must not be mistaken for true epithelia or crystals of in- 
complete triple phosphates, which latter they sometimes resemble more 
pronouncedly than the former. 

In attempting to diagnose the sources of the different epithelia, it 
must be remembered that nothing but size will positively differentiate 




Fig. 49. — Epidermal Scales (X 500). 



them, and that a small number of epithelia may be found, the source of 
which cannot be told positively; the larger number, however, are abso- 
lutely characteristic. 

The epithelia found in the urine may be divided into : First, those 
common to both sexes; second, those found only in the male; and third, 
those found only in the female. 

Epithelia Common to Both Sexes. — The epithelia found in both 
sexes are those from the bladder, the pelves of the kidneys, the ureters, 
and the uriniferous tubules of the kidneys. The urethral epithelia are 
also the same in both sexes, but are most common in the male. 

Epithelia from the Bladder (see Fig. 50). — The epithelia from the blad- 
der are of three distinct varieties and are easily recognizable; these are 
flat epithelia from the upper layers, cuboidal from the middle layers, and 
columnar from the deepest layer. Flat epithelia may be seen both in 
front view and edgewise, when they may appear more or less folded. A 
small number of these epithelia, without the presence of pus-corpuscles, 



134 



URINARY ANALYSIS AND DIAGNOSIS. 



may be seen in every normal urine. They have no significance whatever, 
since the flat epithelia continually desquamate in health, though in a 
small amount only. As soon as they occur with pus-corpuscles and with 
cuboidal epithelia, they have a pathological significance. These flat epi- 
thelia may be seen either singly or in clusters of varying size. Although 



UF 




Fig. 50. — Epithelia from the Bladder (X 500). 
U, Upper layers ; UF, upper layers, folded ; M , middle layers ; D, deepest layer. 



the size of these epithelia is distinctly smaller than that of the epithelia 
from the upper layers of the vagina, a small number may occasionally be 
found, of almost the same size as the latter, derived from the neck of the 
bladder, near the prostate gland. Their number, together with the size 



EPITHELIA. 135 

of the cuboidal epithelia and the fact of their not containing bacteria, is 
as a rule sufficient to clear up the diagnosis. 

Cuboidal epithelia from the middle layers are never found in normal 
urine: they may be scanty or numerous. When cuboidal epithelia are 
present in moderate or large numbers, with many flat epithelia from the 
upper layers, the diagnosis of an acute process can be made. If, on the 
other hand, the upper layers are scanty or entirely absent, the process is 
a chronic one. Whenever fresh exacerbations of an old process set in, 
the flat epithelia become more numerous. 

Columnar epithelia from the deepest layer of the bladder are found 
only in the severer processes, such as intense inflammation, ulceration, 
hemorrhage, and tumors. Care must be taken not to mistake the folded 
upper layers for these more coarsely granular and more highly re- 
fractive epithelia — those from the upper layers being paler and finely 
granular. 

Mention should here be made of an occurrence, winch, though it may 
be found in the epithelia of any organ, is most pronounced in the larger 
cuboidal epithelia of the bladder. In different epithelia from the middle 
layers, a number of nuclei or even newly formed, so-called endogenous 
pus-corpuscles will be found. Their number varies from two to four, five, 
or even more. That pus-corpuscles are formed within epithelia can be 
easily observed. A few of these new-formations can often be seen in dif- 
ferent inflammations, but larger numbers will be found in the epithelia 
only after a long-continued irritation through some pressure, usually 
from the outside. Such endogenous new-formations are seen in cases of 
hypertrophied prostate gland, undoubtedly caused by pressure of that 
organ upon the bladder, as well as in different exudations behind the 
bladder, such as a parametritic exudate or a tumor in the wall or vicinity 
of the bladder. 

All cuboidal and columnar epithelia may contain a varying number 
of secondarily developed, glistening fat-granules and -globules similar to 
those seen in the pus-corpuscles. This is invariably an indication that 
the process has lasted for some time and is not an acute one. A large 
number of these globules always indicates a chronic process. 

Epithelia from Pelvis oj Kidney (see Fig. 51). — In the pelves of the 
kidneys the epithelia also van* considerably in shape, being partly globu- 
lar, but mostly irregular. They are smaller than those from the bladder, 
but larger than those from the ureters, the epithelia from which latter 
are almost always present with those from the pelves. The majority of 
the pelvic epithelia are caudate, pear-shaped, or lenticular, though they 
are sometimes quite irregular; the regular, cuboidal shapes, smaller than 
those from the bladder, being less numerous. The epithelia are frequently 



136 



URINARY ANALYSIS AND DIAGNOSIS. 



seen with uric-acid gravel, which causes an irritation or inflammation of 
the pelvis. 

Epithelia from the Ureters. — Epithelia from the ureters are rarely 
found alone, but usually with those from the pelvis. Their characteristic 
shape in the urine in most cases is round, globular, or slightly irregular, 




Fig. 51. — Epithelia from Pelvis of Kidney and Ureter (X 500). 
P, Pelvis of kidney; U , ureter. 



being distinctly smaller than those from the pelvis. They cannot be dif- 
ferentiated from the epithelia of the prostate gland, which they closely 
resemble. Their number in the urine is, as a rule, small; and the fact of 
their being associated with epithelia from the kidney and pelvis of kidney 
makes their diagnosis easy. Occasionally small columnar epithelia from 
the deepest layer are seen. These are caudate or pear-shaped and are 
found in deep-seated processes, such as ulcerations due to impacted cal- 
culi or tubercular lesions. In traumatism, which may be due to ureteral 
catheterization, they are not rarely present in the urine. 

Epithelia from the Uriniferous Tubules of Kidneys (see Fig. 52). — 
Epithelia from the uriniferous tubules are the most important of all the 
epithelia found in the urine and those most frequently overlooked. When- 
ever they are present in the urine, with pus-corpuscles, even when no 
casts whatever can be found, the diagnosis of a pathological process in 
the kidney is certain, since they are never seen normally in urine. Two 
distinct forms are found: the cuboidal from the convoluted tubules, and 



EP I Til ELI A. 



137 



the columnar from the straight collecting tubules. These epithelia are 
distinctly smaller than either those from the pelvis of the kidney or the 
ureter in the same case, though their sizes vary to a certain degree in dif- 
ferent cases. They are round, globular, or slightly irregular. 

In every case examined the first step is to look for pus-corpuscles, 
which are known to be small in some individuals and comparatively large 
in others, and are usually the smallest granular corpuscles seen. They 
may vary in size in the same case, but to a slight degree only. As soon 
as these are decided upon, the next step is to determine whether bodies 
distinctly larger than these are present. If such bodies, about one-third 
larger than pus-corpuscles, are found in at least moderate numbers, we 
can be certain that they are epithelia from the convoluted and narrow 
tubules of the kidney. The presence or absence of a nucleus has no sig- 
nificance whatever, although such a nucleus is usually found in the kidney 
epithelia, but may be invisible in the pus-corpuscles. The relation be- 
tween the size of the pus-corpuscles and that of the epithelia from the 
convoluted tubules is always the same; that is, the latter are about one- 




Fig. 52. — Epithelia from Urixiferous Tubules of Kidxeys (X 500). 
C, Convoluted tubules; S, straight collecting tubules. 



third larger in diameter than the former. If the pus-corpuscles happen 
to be small in the case examined, the kidney epithelia will be small; but 
if large, the epithelia will be large. 

The comparative sizes of the different smaller formations found in the 
urine are illustrated in Fig. 53. The smallest corpuscles with double con- 



138 URINARY ANALYSIS AND DIAGNOSIS. 

tour, and which are not granular, are the red blood-corpuscles ; the next 
in size, being the smallest granular corpuscles, are the pus-corpuscles; 
then follow the smallest epithelia found in urine, one-third larger than 
the pus-corpuscles — the epithelia from the convoluted tubules of the kid- 
ney. Finally, the next larger epithelia are shown, always about twice the 



®@<§> ® © m w w& 

Fig. 53. — Comparative Sizes of Corpuscles and Epithelia (X 500). 

diameter of the pus-corpuscles, which are either those from the ureters or 
the prostate gland, between which no difference can be noticed. If this 
relationship is kept in mind, no mistake can be made, though it must be 
remembered that when an individual small formation is found, the diag- 
nosis cannot be made positively until compared with the pus-corpuscles. 

Besides the cuboidal epithelia, columnar epithelia from the straight 
collecting tubules are sometimes found. The latter are, as a rule, not as 
abundant as the former, and are almost invariably seen in larger numbers 
in the severer cases of nephritis only. Their size, as compared with that 
of the cuboidal epithelia, is about the same, they being narrower, but 
elongated. In very acute cases of nephritis clusters of kidney epithelia, 
as well as cast-like tubes of epithelia, though not necessarily true casts, 
may be found. 

Although it is the usual custom to rely entirely upon the presence of 
casts in the urine before making the diagnosis of a nephritis, it will be 
found that casts are frequently absent, even in pronounced cases of kid- 
ney inflammations, as, for instance, in catarrhal or interstitial nephritis; 
and that even in cirrhosis of the kidney, casts are, as a rule, entirely ab- 
sent, or, if present, are extremely scanty. If care is taken to look for 
epithelia about one- third larger than pus-corpuscles, the diagnosis of a 
nephritis can be made in many cases which are otherwise overlooked, 
even though a small or even moderate amount of albumin be present in 
the urine. Too much stress cannot be laid upon this fact, as, in many 
cases where the clinical symptoms undoubtedly point to a nephritis, the 
diagnosis is abandoned because no casts are found. This variety of 
nephritis is much more common than is usually supposed, though in 
most cases of a milder character than the parenchymatous variety, and 
it may often last for a number of years without being detected. 

The diagnosis of epithelia from the upper urinary tract has of late 



EPITHELIA. 



139 



years been simplified by ureteral catheterization. Whenever such urines, 
obtained by means of the ureteral catheter, are examined, where the 
presence of epithelia from the bladder or the genital tract can positively 
be excluded, only those epithelia which have been described as being de- 
rived from the ureter, pelvis of kidney, and uriniferous tubules are found. 

Epithelia Found in Urine of Male. — The epithelia found in the urine 
of the male are those from the urethra, the prostate gland and its duct, 
the seminal vesicles, and the ejaculatory duct. 

Epithelia from Urethra (see Fig. 54). — The epithelia from the urethra 
vary considerably in size and shape, being partly flat, partly cuboidal, 
and partly columnar, and in most cases are comparatively large and ir- 
regular, so that they can be easily diagnosed. The larger irregular, partly 
flat, partly cuboidal epithelia are seen in milder inflammations, such as 
the first stages of catarrhal or gonorrhoeal inflammations; the irregular 
columnar or cylindrical epithelia occur only in deeply seated inflamma- 
tions or ulcerations, which often lead to the formation of a stricture. 

Epithelia from Prostate Gland (see Fig. 55). — The epithelia from the 
prostate gland are partly cuboidal and partly columnar, the latter orig- 




Fig. 54. — Epithelia from Urethra (X 500). 



inating both in the alveoli and the excretory ducts of the gland. The 
cuboidal epithelia are of exactly the same size as the cuboidal epithelia 
from the ureters, being about twice as large as the pus-corpuscles in every 
case, and distinctly larger than those from the convoluted tubules of the 



140 



URINARY ANALYSIS AND DIAGNOSIS. 



kidney. When epithelia of this size are seen in a given case, care must 
be observed to take the relative numbers of these, as well as of those from 
the convoluted tubules and the pelvis of the kidney, into consideration 
before reaching a positive diagnosis. For instance, if they are present in 
large numbers, while those from the kidneys and pelves are entirely ab- 




Fig. 55. — Epithelia from Prostate Gland, Seminal Vesicles, and Ejactjlatory 

Ducts (X 500). 
P, Prostate gland and its ducts; E, ejaculatory ducts; S, seminal vesicles. 



sent or seen in small numbers only, they are undoubtedly prostatic. The 
clinical history, if known, will, of course, clear up this point still further. 

The columnar epithelia, partly from the ducts of the gland, which are 
distinctly larger than those from the straight collecting tubules of the 
kidney, are rarely absent in pathological processes of the prostate gland, 
and will render the diagnosis plain, since columnar epithelia from the 
ureters, which they resemble, are not frequently seen, and, when present, 
are usually found in small numbers only. The latter also are more cau- 
date than the former. 

In many cases of posterior urethritis associated with prostatitis, 
groups of round, oval, or slightly irregular epithelia are found. These 
are larger than the prostatic epithelia just described, resembling in size 
the cuboidal epithelia from the pelvis of the kidney, but are pale, usually 
finely granular, with their nuclei frequently indistinct. They are hy- 
dropic, and may be derived from both the prostate gland and the pros- 
tatic portion of the urethra. 

Mention should be made here of the fact that in rarer cases pale, con- 



EPITHKL1A 



141 



centric formations of varying sizes are found with the prostatic epithelia. 
These are the so-called prostatic concretions, colloid or amyloid corpus- 
cles of the prostate gland (see Fig. 56). They are irregular, partly oval, 
partly angular bodies, which have a high refraction and a more or less 
pronounced concentric striation, frequently with an irregular central nu- 
cleus. Their number seems to be augmented in some cases of hyper- 
trophy of the gland. 

Epithelia from Seminal Vesicles. — Epithelia from the seminal vesicles 
(see Fig. 55) are frequently associated with those from the prostate gland. 
Their presence in urine with pus-corpuscles indicates an inflammation or 
suppuration in the vesicles. These epithelia are always columnar and 
non- ciliated. They are more or less irregular, either of the same size or 
slightly larger than the columnar epithelia from the prostate, and in the 
organ contain yellow pigment. The pigment is sometimes, but not al- 
ways, seen in the epithelia in urine. 

Epithelia from Ejaculatory Ducts. — Epithelia from the ejaculatory 
ducts mav also be found in the urine. They are of the columnar ciliated 




Fig. 56. — Sperma as Fouxd in Ubixe (X 500). 

variety, and perfectly characteristic. The cilia are not always seen, since 
they break off easily and become lost; but delicate parallel rods in the 
interior of the epithelia, near their basal surface, may then indicate that 
the epithelia were originally ciliated. When no cilia or rods are found, 
their size alone will usually be sufficient for a diagnosis, as they are 
smaller and considerably narrower than those from the bladder. 



142 URINARY ANALYSIS AND DIAGNOSIS. 

Sperma. — Not infrequently sperma, the characteristic ingredients of 
which are the spermatozoa, is found in urine, normally as well as patho- 
logically. This will be the case after sexual intercourse, as well as after 
emissions, and in spermatorrhoea, which latter can best be diagnosed 
from the almost constant presence of sperma in urine, especially the first 
urine voided in the morning. When sperma is found in small amount 
only, the appearance of the urine is not changed; but when present in 
large amount, cloudy, flaky deposits are seen, which, when examined, 
prove to be sperma. 

In urine the positive diagnosis of sperma can only be made when 
spermatozoa are found, though prostatic epithelia, and occasionally sper- 
matic concretions, may be present (see Fig. 56). The other ingredients 
of sperma, such as the sperma crystals, are rarely seen in urine. 

Spermatozoa, which are about ^l^ or g-J-g- of an inch long, consist of a 
flattened, oval, or pear-shaped head, a small cylindrical middle portion 
or neck, which, however, is not always seen, and a long, wavy, tapering 
tail, considerably broader at the head than at the end. In perfectly fresh 
urine a slight motion of the spermatozoa may be visible for a short time, 
but disappears very soon. They are extremely resistant toward chem- 
ical reagents, and may be found well preserved in urine after days, even 
when it is strongly alkaline. 

The number of spermatozoa in urine varies greatly. Under normal 
conditions the spermatozoa are rarely abundant, while in cases of sperma- 
torrhoea they are usually quite numerous and may be present in very 
large numbers. In cases of spermatocystitis or seminal vesiculitis they 
are frequently seen, and many of them will be found changed, the head 
gradually enlarging, becoming more round and often granular. It is not 
unusual for the head to assume the size of a pus-corpuscle, which it may 
resemble to such a degree that it is impossible to differentiate it from the 
latter; in appearance, it is like a pus-corpuscle with a tail. In these cases 
pus-corpuscles, epithelia from the prostate gland, from the seminal ves- 
icles, and frequently also from the ejaculatory ducts will be present. 

Urethral and Gleet-Threads. — Although no distinction should be made 
between urethral and gleet-threads or filaments (the latter originating in 
the urethra), there are cases in which men who have never suffered from 
gonorrhoea will void small, transparent mucus-threads or filaments with 
the first morning urine. These are always scanty, and consist of nothing 
but mucus, both threads and corpuscles, together with the larger, flat, 
superficial urethral epithelia. These masses are conglomerations of mu- 
cus in the urethra, and are not pathological. 

On the other hand, we find in the urine of persons who have suffered 
from gonorrhoea, at one time or another, either only a short time pre- 



EPITHELIA. 



143 



viously or many years before, a varying number of filaments, which dif- 
fer in size and may appear either perfectly transparent or more or less 
opaque. These are the regular gleet- threads (see Fig. 57) . 

It is not uncommon to find such filaments accidentally in the urine of 
persons who, though they suffered from gonorrhoea a long time previ- 
ously, have not noticed any symptoms for years. In these cases they 
are, of course, small and scanty. More frequently are they found in 
those cases of chronic gonorrhoea in which slight symptoms, such as a 
moisture at the orifice of the urethra or an adhesion of the lips of the 




Fig. 57. — Gleet-Threads ( X 500). 

PC, Pus-corpuscles; M, mucus-fibres; PE, epithelium from the prostate gland; DE, 

epithelium from the ducts of the prostate gland ; UE, epithelium from the urethra. 



meatus in the morning, with subsequent discharge of a minute drop of 
either mucous or muco-purulent fluid, are present. The number of fila- 
ments in cases of this kind is at times very large. Fortunately, gonococci 
are not found in all these cases, but may be entirely absent in the larger 
number, and repeated careful examinations will fail to find them. 

Regular gleet-threads consist of mucus, pus-corpuscles (the latter usu- 
ally abundant in the more pronounced cases), and a varying number of 
epithelia from the urethra and the prostate gland ; sometimes, also, from 
the neck of the bladder. The larger number of pus-corpuscles, as well as 
most of the epithelia, will be found studded with fat-globules and -gran- 



144 



URINARY ANALYSIS AND DIAGNOSIS. 



ules, which latter are not infrequently seen in smaller or larger groups 
upon and between the mucus, outside of the pus-corpuscles and epithelia. 
The more chronic the case, the more numerous are the fat-globules. The 
appearance of such so-called gleet-threads under the microscope is always 



UF 




Fig. 58. — Epithelia from the Vagina (X 500). 
U, Upper layers; UF, upper layers folded; M, middle layers; D, deepest layer. 



perfectly characteristic, though the name is misleading, since, when they 
are large, a number of fields can be found crowded with pus-corpuscles, 
mucus, and epithelia not in the least resembling a thread. 

The more severe the case, the more abundant are the pus-corpuscles, 



EPITHELIA. 145 

and care is necessary in such cases not to make an error in the diagnosis, 
which would be easy when the presence of gleet-threads is not suspected. 
A wrong diagnosis of an abscess might thus be made, although such a 
diagnosis is never justified without the presence of a number of connective- 
tissue shreds, which are never seen here. In the milder forms the mucus 
is abundant, and the pus-corpuscles mixed with it often change and as- 
sume various irregular shapes, the spindle shape being frequent. It is 
impossible to judge of the chronicity of a case from these, as has been 
claimed. Again, the pus-corpuscles may swell and become hydropic, or 
the cover glass may have been accidentally pressed in mounting the speci- 
men, either of which is sufficient to change the appearance of the pus- 
corpuscles. Spermatozoa may at times be found mixed with the gleet- 
threads, but will, of course, not affect the diagnosis in any form. 

Epithelia Found in Urine of Female. — The epithelia found in the 
urine of the female are those from the vagina, the Bartholinian gland, 
the cervix of the uterus, and the mucosa of the uterus. 

Epithelia from Vagina. — The epithelia from the vagina are the largest 
found in the urine; those from the upper layers are flat, those from the 
middle layers are cuboidal, and those from the deepest layer are colum- 
nar (see Fig. 58). 

The flat epithelia are present in varying numbers in most female 
urines, and when found alone have no significance, since they continually 
desquamate in health. When leucorrhcea is present, as is almost always 
the case, in a small degree, in healthy women who have borne children, 
their number is considerably augmented. They may be found singly or 
in variously sized clusters, and are always large, irregular, and usually 
studded with bacteria — both cocci and bacilli. They frequently contain 
large fat-globules, which, of course, have here no significance; they are 
often seen folded or edgewise, when they are narrow but irregular, and 
cannot be mistaken for columnar epithelia. Their granulation is fine, and 
the epithelia, therefore, pale. 

The cuboidal epithelia from the middle layers are abundant in inflam- 
mations of the vagina. They are considerably larger than those from the 
bladder, have one or more nuclei, and in chronic inflammations contain 
fat-granules and -globules. These are also found in clusters of consider- 
able size. 

The columnar epithelia from the deepest layer, much larger than 
those from the bladder, are seen only in intense, deep-seated inflamma- 
tions or ulcerations, where they may sometimes be found in large num- 
bers. 

Smegma. — Of common occurrence in the urine of the female are clus- 
ters of epidermal scales, so-called smegma, partly from the clitoris, partly 
10 



146 



URINARY ANALYSIS AND DIAGNOSIS. 



from the labia, or from the vagina. Smegma may also be found in small 
amount in the male, from the prepuce, but here it is not so common nor 
seen in such enormous masses as in the female (see Fig. 59) . 

Smegma consists of closely packed masses of variously sized epidermal 
scales filled to a greater or less degree with bacteria — both cocci and ba- 




Fig. 59. — Smegma from the Clitoris (X 450). 



cilli — and also with extraneous fat-globules, as well as particles of dirt. 
The individual scales, as before said, are never nucleated and rarely 
granular, but appear shrunken. Such masses, which have been seen to 
cover an entire field of the microscope, are highly refractive, and when 
large can be seen with the naked eye. 

Epithelia from Bariholinian Gland (see Fig. 60). — The epithelia from 
the Bartholinian gland resemble in size the round or slightly irregular 
epithelia from the prostate gland in the male, being about twice the di- 
ameter of pus-corpuscles. They are frequently present when the vaginal 
epithelia are found in moderate or large quantities. 

Epithelia from Cervix Uteri. — Epithelia from the cervical portion of 
the uterus are partly flat, partly cuboidal, and partly columnar, and quite 
large, though considerably smaller than those from the vagina, and al- 
ways more irregular. These epithelia may be characteristic, but they 
sometimes so resemble the irregular epithelia from the urethra as to be 



EPITHELIA. 



147 



difficult of differentiation. The latter are found in the female as well as 
the male, though generally in smaller numbers. 

Epithelia from Mucosa Uteri. — Epithelia from the mucosa of the 
uterus, indicating a catarrhal endometritis, are also not rare in the urine. 
They are delicate, columnar, ciliated formations, smaller than those de- 
scribed as being derived from the ejaculatory ducts. The cilia on the 
surface of these epithelia are frequently well marked, and as many as 
three or four may be found; occasionally, however, they are broken off. 
With them we may see ciliated pus-corpuscles, which arise from the epi- 
thelia, and cannot come from any other locality than the uterus. In 
freshly voided urine the cilia from both these formations may be seen in 
waving motion. 

If the epithelia just described are carefully studied, we will soon be- 
come convinced that the formations from the different organs of the 
genito-urinary tract can undoubtedly be differentiated, and that diag- 
noses of the different lesions can be made with great certainty. In every 




Fig. 60. — Epithelia from Bartholinian Gland, Cervix Uteri, and Mucosa Uteri 

(X 500). 
BE, Bartholinian gland; CE, cervix uteri; UE, mucosa uteri. 



case in which at least a moderate number of epithelia is found in the 
urine, most of these are characteristic of the organ from which they are 
derived. There will, of course, always be a few, the origin of which 
must remain doubtful, but these are not sufficiently numerous to cause 
errors. The more cases we examine, the more convinced we will be- 



148 URINARY ANALYSIS AND DIAGNOSIS. 

come of this fact. The clinical history of the case will bear out the 
microscopical diagnosis every time, and frequently the microscope gives 
the first indication of some pathological condition which has as yet es- 
caped detection, but which sooner or later is bound to give clinical 
symptoms. In no organ is this more pronounced than in the kidney, 
where mild cases of nephritis, which unfortunately escape detection for 
months or years, may be present, until suddenly the pronounced symp- 
toms of a chronic nephritis or a cirrhosis of the kidney develop. Con- 
scientious examination of the urine for kidney epithelia and pus cor- 
puscles will often repay the physician in cases where, although he has 
found a trace of albumin, he will banish from his mind all idea of an 
inflammation of the kidneys because no casts are present. 



CHAPTER XII. 

MUCUS AND CONNECTIVE TISSUE. 
I. MUCUS. 

Mucus is found in small amount in every normal urine, being, as a 
rule, more abundant in females. It appears in the form of threads and 
corpuscles, and is a normal physiological product of the epithelia (see 
Fig. 61). 

Mucus-threads are finely striated, pale, often scarcely perceptible 
strings of different sizes. In normal urine they are always small; but in 
inflammations, especially those of the genital tract, may assume large 
proportions. The strings are made up of pale, more or less parallel fibres, 
and when large may branch in different directions. 

Besides threads, mucus-corpuscles are of frequent occurrence. These 
corpuscles vary in size from that of a pus-corpuscle to that of larger epi- 
thelia; are pale, more or less irregular in outline, always finely granular, 
and non-nucleated. They are easily distinguished from pus-corpuscles by 
their greatly varying sizes, pale appearance, and absence of a nucleus, 
which latter is seen in finely granular pus-corpuscles. 

Mucus-threads not infrequently appear in the form of delicate, stri- 
ated formations, resembling casts, the so-called cylindroids or mucus- 
casts (see Fig. 62). Although at times greatly resembling hyaline casts 
in their outline, they can usually be distinguished from them by their ir- 
regular contours, their tapering ends, and their more or less striated in- 
terior, since they are nothing but conglomerations of mucus-fibres. They 
may be quite long and are often twisted and folded. They may be found 
whenever mucus is present in larger amounts, and may be derived from 
any portion of the genito-urinary tract. They undoubtedly have no 
further significance than mucus in general. 

Mucus is greatly augmented in all inflammatory conditions, but more 
especially in inflammations of the bladder and the genital organs, such as 
the urethra, prostate gland, and vagina. In the latter, mucus-threads 
are often large, cylindrical, and twisted, and may be perceptible to the 
naked eye. The so-called gleet-threads are nothing but conglomerations 
of mucus, in which large numbers of pus-corpuscles and epithelia are em- 

149 



150 



URINARY ANALYSIS AND DIAGNOSIS. 



bedded. Irritation of the urinary tract, due to highly acid urine, con- 
taining uric acid and sodium urate, increases the amount of mucus, and, 
the urates being precipitated upon it, the stringy masses become more 
easily perceptible. Fat-granules and -globules, so frequently found in the 
urine, may also conglomerate upon mucus-threads and so-called cylin- 
droids. 

In chronic inflammations of the bladder the urine appears ropy, on 




Fig. 61. — Mucus-Threads and -Corpuscles (X 500). 



account of the abundance of mucus. Simple irritation of the sexual or- 
gans is sufficient to increase the amount of mucus, and if sperma is mixed 
with the urine its mucous constituents appear as pale, flaky masses en- 
tangled with spermatozoa. 

Finally, an increased amount of mucus may be seen in the urine in 



MUCUS AND CONNECTIVE TISSUE. 



151 



different febrile conditions, without any inflammation in the urinary 
tract; and in acute contagious diseases, such as scarlet fever, it fre- 
quently appears as a precursor of a nephritis. 




Fig. 62. — Mucus-Casts or Cylixdroids (X 500). 



II. CONNECTIVE TISSUE. 



As all the organs containing epithelia also contain connective tissue, 
it is evident that this formation can frequently be found in the urine, 
though only in the more intense, deeper-seated pathological processes. 
Its occurrence has, however, been entirely overlooked, except in the rare 
cases in which particles of tumors, especially from cancers, have been found 
in the urine. That connectivo-tissue shreds are of comparatively common 



152 URINARY ANALYSIS AND DIAGNOSIS. 

occurrence was first pointed out by Carl Heitzmann, who described their 
appearance under a number of different conditions. The reason for their 
being overlooked seems to be, partly, that in many cases they are small, 
though easily seen, and partly that they have been mistaken for mucus- 
strings or extraneous substances, such as linen and cotton fibres. 




Connective-tissue Shreds ( X 500). 



Connective-tissue shreds (see Fig. 63) vary in size, and are made up 
of wavy, moderately refractive fibres, the individual fibres being rarely 
single, but conglomerated in the form of small, irregular bundles, which 
again form larger bundles. These bundles, then, are always fibrillary and 
frequently finely granular, sometimes even containing formations resem- 
bling nuclei — the connective-tissue corpuscles. They may be so small 
and delicate as entirely to escape detection with a magnifying power of 



MUCUS AND CONNECTIVE TISSUE. 153 

less than 500 diameters, or so large as to cover half or even the entire 
length of a field, and of varying thickness. They are easily differentiated 
from mucus-threads by their moderate refraction and their wavy, irregu- 
lar fibres, in contradistinction to the pale appearance and more or less 
regular fibres of mucus, which frequently run in a parallel direction for a 
considerable distance. On the other hand, linen fibres, or, rather, the 
smaller fibrilla? of linen, with which they might also be confounded, are 
of a still higher refraction, and are coarser, the individual fibrillar being 
split up in an entirely different manner, and are never as wavy as the 
connective-tissue shreds. 

The pathological conditions under which connective-tissue shreds are 
found may be divided into the following: 

1. Ulceration. 

2. Suppuration. 

3. Hemorrhage. 

4. Traumatism. 

5. Tumors. 

6. Hypertrophy of the prostate gland, with inflammation of 

that organ. 

7. Stricture of the urethra. 

8. Cirrhosis of the kidney. 

9. Atrophy of the kidney. 

10. In all other intense inflammatory processes, but in small 
amount only. 
As an example of the latter, the croupous or parenchymatous inflam- 
mation of the kidney may be mentioned, in which, if it is at all severe, 
connective-tissue shreds will be found in small numbers. 

1. Ulceration. — Ulcerative processes are quite common occurrences, 
and may be found in any part of the genito-urinary tract, but more espe- 
cially in the bladder, pelvis of kidney, urethra, and vagina. In such 
ulcers the connective-tissue shreds are usually broad and numerous, pus- 
corpuscles are present in moderate or fairly large numbers, and the loca- 
tion of the ulcer can always be determined by the presence of the charac- 
teristic epithelia ; these are abundant, and found not only from the more 
superficial, but also from the deeper layers. Besides these formations, 
the freshly voided urine contains variously sized conglomerations of 
cocci, in the form of zoogla^a masses, especially around the connective- 
tissue shreds, as well as small numbers of other bacteria. 

2. Suppuration. — The presence of an abscess in any organ can be 
diagnosed when connective-tissue shreds in large numbers are seen with 
numerous pus-corpuscles and epithelia from the organ in which the ab- 
scess is situated, this being most frequently either the kidney, the pelvis 



154 URINARY ANALYSIS AND DIAGNOSIS. 

of the kidney, the prostate gland, or the seminal vesicles. In many cases 
we will also see pronounced endogenous new-formations in the epithelia 
of the neighboring organs, as the result of pressure upon that organ. 
An abscess of the prostate gland, for instance, may give endogenous new- 
formations in the epithelia of the bladder, as well as of the urethra. 
Large numbers of pus-corpuscles and epithelia alone, without the pres- 
ence of connective-tissue shreds, are never sufficient to diagnose an ab- 
scess. As soon, however, as these shreds, showing a destructive process, 
are found, the diagnosis becomes plain. The connective-tissue shreds, 
although always quite numerous, may vary considerably in size. 

3. Hemorrhage. — In hemorrhages of the genito-urinary tract, it is 
often quite difficult to find the epithelia showing their source — the more 
abundant the hemorrhage, the greater the difficulty. It sometimes re- 
quires hours to arrive at a definite conclusion, though a certain number 
of epithelia will always be found sooner or later. In all such cases con- 
nective-tissue shreds are present, but are occasionally quite scanty and 
small, except when the hemorrhage is due to a tumor. They have, as a 
rule, a yellowish tint, from the coloring matter of the blood. In hemor- 
rhages red blood-corpuscles are very abundant, and white blood-corpus- 
cles are generally seen in small numbers. Strings of fibrin, which must 
not be mistaken for connective tissue, are found in many of these cases, 
but pus-corpuscles are absent as long as there is no inflammation; if a 
hemorrhage intervenes upon an inflammation, all the evidences of the 
latter will, of course, be present with the former. 

4. Traumatism. — Since traumatism, due to various causes, is frequently 
accompanied by hemorrhages or even ulcerations, the features would be 
those above given. There are, however, cases in which the injury does 
not cause a pronounced hemorrhage, yet the destructive process to the 
tissue is sufficient for connective- tissue shreds to appear in the urine, 
with but a few red blood-corpuscles. Among these may be mentioned 
slight injuries, due to the passage of a small amount of gravel; injury to 
the ureter, due to the passage of the ureteral catheter, which may be 
quite extensive; mechanical injury of the orifice of the vagina, due to 
masturbation; or injuries of the cervix uteri. In mechanical injuries, 
such as are caused by masturbation, vaginal epithelia from all three 
layers are found, together with a large number of epidermal scales from 
the labia, usually containing fat-globules, epithelia from the Bartholinian 
gland, a few pus-corpuscles, possibly a few red blood-corpuscles, and a 
small or moderate number of connective-tissue shreds. When the num- 
ber of vaginal epithelia is not large, and connective-tissue shreds appear 
with numerous irregular epithelia from the cervix, with only a few pus- 
corpuscles, injuries around the cervix are indicated. Although of com- 



Ml'CCS AND CONNECTIVE TISSUE. 155 

paratively small practical importance, it must be known that connective- 
tissue shreds in the urine of females may be due to such causes. 

5. Tumors. — In all tumors which can be diagnosed from the urine, 
such as papilloma, sarcoma, and cancer, connective-tissue shreds are the 
most important diagnostic features, without which the presence of a tu- 




Fig. 64. — Connective-tissue Shreds Found in Tumors (X 500). 

mor cannot be positively diagnosed. Besides these, other evidences of a 
tumor are frequently found, though the connective-tissue shreds them- 
selves may be characteristic enough for a diagnosis. 

In papilloma such shreds are always large, very irregular, frequently 
branched, and often assume the shape of coils or knobs (see Fig. 64). 



156 URINARY ANALYSIS AND DIAGNOSIS. 

They are coarsely granular and may contain a number of inflammatory 
corpuscles. In rare cases blood-vessels in process of formation or fully 
developed may also be found in them. Besides these large masses, the 
regular connective-tissue shreds are also present in varying amount. A 
number of irregular, coarsely granular epithelia, the covering epithelia of 
the papilloma, will usually be seen in such cases, though they are not 
found in situ and are not of much value for a diagnosis. 

In cancer of the bladder, especially villous or papillary, the connec- 
tive-tissue shreds are occasionally still larger and more irregular, forming 
so-called cauliflower-like excrescences. They are infiltrated with inflam- 
matory corpuscles, sometimes to a great degree, and often contain large 
cancer epithelia or even epithelial nests. Besides these shreds, such 
cases contain a varying number of epithelia about the size of those from 
the middle layers of the bladder, but extremely irregular, coarsely granu- 
lar, and having numerous nuclei or pus-corpuscles in their interior — the 
so-called endogenous new-formations. In rarer cases variously sized can- 
cer nests are also present. As a rule, both the connective-tissue shreds 
and the epithelia are seen crowded with fat-globules and -granules. The 
epithelia alone are never sufficient for a diagnosis, but as soon as the 
shreds just described are present the case becomes plain. That pus-cor- 
puscles, bladder epithelia, and usually red blood-corpuscles are always 
found in these tumors is evident. 

In sarcoma, which can develop in any organ of the genito-urinary tract 
and the location of which can be diagnosed according to the epithelia 
present, the connective-tissue shreds are frequently of very large size, but 
not characteristic. Here peculiar, glistening, coarsely granular, almost 
homogeneous corpuscles, smaller than pus-corpuscles but larger than red 
blood-corpuscles, are found in large numbers and variously sized groups. 

6. Hypertrophy of Prostate Gland. — An enlargement of the prostate 
gland, when slight and unaccompanied by an inflammation, does not 
give connective-tissue shreds in the urine. As soon, however, as the 
hypertrophy becomes more pronounced and is accompanied by an in- 
flammation, connective-tissue shreds, which may be small and scanty, 
appear in the urine, with pus-corpuscles and epithelia from the prostate 
gland and duct. Besides these features, we usually find the endogenous 
new-formations in the epithelia of the bladder or urethra, or both. 

7. Stricture of Urethra. — A diagnosis of stricture of the urethra can 
also be made in a number of cases from an examination of the urine. 
This is of little practical value. In these cases cuboidal and columnar 
epithelia from the urethra, many of which have pronounced endogenous 
new-formations, are found with pus-corpuscles, red blood-corpuscles, and 
connective-tissue shreds in varying numbers. The features of an existing 



M I r C I \S AND CONNECTIVE TISS UE. 157 

hypertrophy of the prostate or a stricture of the urethra are not neces- 
sarily found in every specimen of urine. 

8, 9. Cirrhosis and Atrophy of Kidney. — Every chronic interstitial 
nephritis sooner or later leads to cirrhosis of the kidney, and every chronic 
parenchymatous nephritis to atrophy of the kidney. In both of these af- 
fections connective-tissue shreds are also present, usually in small amount 
only in cirrhosis, but always in larger amount in atrophy. The features 
found in the urine in these diseases, besides connective-tissue shreds, are 
numerous and so constant that a diagnosis is simple. 

10. That connective-tissue shreds may be also found in small num- 
bers in every intense inflammation, is evident from what has been said. 
In tuberculosis of any organ of the geni to-urinary tract, for instance, 
even if as yet unaccompanied by ulceration, a few shreds may be present 
in the urine. As soon as connective-tissue shreds, however small, are 
found, it becomes evident that the pathological process cannot be a mild 
one. 



CHAPTER XIII. 

TUBULAR CASTS. 

Tubular casts were first carefully described as occurring in the tu- 
bules of the kidney and found in the urine by Henle in the year 1842, al- 
though they were probably seen a few years before that time by different 
observers. Many years later, in 1867, Rovida gave a thorough account 
of their nature and formation. Henle considered them to be coagulated 
fibrin, but the views concerning their origin have become greatly changed 
since that time. They were at one time considered to be products of 
secretion of the epithelia of the tubules, at another time to be transformed 
or disintegrated epithelia. Later on, the blood-vessels were supposed to 
be principally concerned in their production, at least in that of the hya- 
line casts, without any participation of the epithelia. 

One of the older views was that casts are produced by the coagula- 
tion of an albuminous substance, the supposition being based upon the 
fact that the presence of casts in the urine depends upon the admixture 
of albumin, since they are found in conditions accompanied by albumin; 
and the more abundant the albumin, the more likely it is that casts are 
present. This view seems to be nearly correct. Casts are probably the 
products of an albuminous exudation from the blood-vessels, with the 
addition of the swollen and destroyed epithelia. In almost all cases 
where casts are present, albumin is found in moderate or large amount; 
but there are undoubtedly cases in which the amount of albumin is small, 
and, it is claimed, may even be entirely absent. The latter is, however, 
doubtful. The amount of albumin may be so small as to escape detection 
by the usual chemical methods employed; but, according to this view of 
their formation, it would seem that a small amount, at least, must be 
present in every case. 

The appearance of casts in the urine is always of the highest diagnos- 
tic importance, and, if found in any amount, they indicate the presence 
of a croupous or parenchymatous nephritis, the more so the larger the 
accompanying amount of albumin. It is asserted that a mere hyperemia 
of the kidneys may suffice to throw casts into the urine, and also that 
casts can be found in small numbers when the kidneys are perfectly in- 
tact. They have been described in cases of gastro-intestinal catarrh, in 

158 



TUBULAR CASTS. 159 

jaundice, acute and chronic anaemia, as well as in nervous affections of 
different kinds, without any accompanying inflammation of the kidneys. 
As they have been found in small numbers only in all such cases, it is a 
question whether true casts were seen, or only cylindroids, which at 
times it is almost impossible to distinguish from hyaline casts. In the 
majority of cases the presence of tube casts signifies the presence of a 
nephritis, but small numbers of hyaline casts may be found in renal 
congestion, unaccompanied by an inflammation. 

In order to guard against any errors in the diagnosis* it is important 
to look for other abnormal features in the urine, when cast-like forma- 
tions are seen; when none are found, such formations cannot be tube 
casts. It is not always easy to find casts in the urine, especially if only 
a few hyaline casts are present. The centrifuge throws them down 
readily, but unless the urine is centrifugalized for no more than three 
minutes, small numbers of casts may break up and escape detection. 
Again, cylindroids are more liable to be found in a centrifugalized speci- 
men, and these may be mistaken for true hyaline casts. It is perhaps 
the safest plan to allow the urine to settle in a conical vessel for from six 
to twelve hours, provided it can be kept in a cool place, so that no pu- 
trefactive changes occur. Low magnifying powers are unreliable for the 
detection of casts, and a power of at least 400 diameters should always 
be used. Again, a number of specimens should be examined before 
positively determining as to the absence of casts. 

Casts have been divided in many different ways, but perhaps the 
simplest is to divide them into true casts and false or pseudo-casts. The 
former alone denote the presence of a nephritis, while the latter are 
accidental formations. 

I. TRUE CASTS. 

True tube casts are of six varieties. These are: 

1. Hyaline casts. 

2. Epithelial casts. 

3. Blood casts. 

4. Granular casts. 

5. Fatty casts. 

6. Waxy casts. 

Generally speaking, the first three varieties — hyaline, epithelial, and 
blood casts — are found in an acute parenchymatous or croupous neph- 
ritis, while the last three — i.e., granular, fatty, and waxy casts — are 
found in a chronic parenchymatous inflammation of the kidney. In the 
first few weeks of the inflammation, granular and fatty casts rarely ap- 
pear, waxy casts never; but as soon as the absolutely acute attack com- 



160 URINARY ANALYSIS AND DIAGNOSIS. 

mences to subside and the inflammation assumes a more subacute form, 
granular casts, first in small, then in large numbers, are always seen, 
while the hyaline and epithelial casts are still abundant. Fatty and 
waxy casts are secondary products, and are rarely found until a nephritis 
has lasted for some time, although mixed epithelial and granular casts, 
commencing to become fatty, may be found a few weeks after the begin- 
ning of the inflammation. Exceptionally, as in phosphorus poisoning, 
fatty casts may be present at once. 

All true casts may appear in three distinct sizes, according to the por- 
tion of the uriniferous tubules from which they originate. The narrowest 
casts are those formed in the narrow tubules, the next in size from the 
distal convoluted tubules, while the largest are always formed in the 
straight collecting tubules. Casts from the proximal convoluted tubules, 
those directly arising from the capsule of the tuft, never appear in the 
urine, since they cannot pass the narrow tubules. 

Although not generally admitted, a great prognostic value undoubt- 
edly attaches to the size of the casts. The mildest degrees of the disease 
are usually indicated by casts from the narrow tubules, and a small num- 
ber of casts from the convoluted tubules. Not infrequently pedunculated 
casts are met with; that is, formations from the place of transition of the 
narrow tubules into the distal convoluted tubules. Casts from the con- 
voluted tubules justify the diagnosis of parenchymatous nephritis in the 
cortical substance. Casts of all three sizes, the largest arising from the 
straight collecting tubules, permit of a conclusion of parenchymatous ne- 
phritis in the whole organ, and upon this condition a very unfavorable 
prognosis can be established. 

Based upon these simple facts, a good or bad prognosis can be given 
in many cases where the clinical features are too obscure to be of any 
practical value; and not infrequently the bad prognosis, which has to be 
given on account of the presence of many large casts from the straight 
collecting tubules, and which does not at first seem justified by the scar- 
city of clinical symptoms, is soon borne out by the fatal end of the case. 

Repeated examinations of urine, especially from a mixed twenty- 
four hours' voiding, should always be made before an opinion as to 
the prognosis of a case can be of any value. Ail the features, both 
chemical and microscopical, must invariably be taken into considera- 
tion. The determination of the amount of urea excreted in twenty- 
four hours, the total solids and the amount of albumin are of as much 
importance as the number and character of the pathological elements 
seen under the microscope. 

1. Hyaline Casts (see Fig. 65). — Hyaline casts are pale, transparent 
formations of variable length, sometimes of considerable size, and not in- 



TUBULAR CASTS. 161 

frequently difficult of detection in the urine. Those from the convoluted 
and straight collecting tubules are usually more or less regular, though the 
latter may be very broad ; those from the narrow tubules are occasionally 
tortuous or spiral, and at times exceedingly narrow and delicate. As a 
rule, these casts are absolutely structureless, but at times a pale granula- 




Fig. 65. — Hyaline Casts (X 500). 

Upper row, from convoluted tubules ; middle row, from narrow tubules ; lowest row, 

from straight collecting tubules. 

tion is noticeable in them, though this is not sufficiently marked to allow 
of their classification as granular casts. Different formations, such as pus- 
corpuscles and fat-globules, may be seen upon them in small numbers, 
but are accidental and do not change the diagnosis. In rare cases these 

casts may appear more solid and of higher refraction, though their hya- 
11 



162 URINARY ANALYSIS AND DIAGNOSIS. 

line character is undoubted, and they must not be mistaken for waxy 
casts. 

When very delicate and pale, it has been advised to color the casts by 
the addition of a drop of iodine-iodide of potash solution (iodine, 1 part; 
iodide of potash, 2 parts; water, 300 parts) upon the slide, which will 
stain them yellow and render them more distinct. This is rarely neces- 




Fig. 66. — Epithelial Casts (X 500). 

Upper row, from convoluted tubules ; middle row, from narrow tubules ; lowest row, 

from straight collecting tubules. 

sary, since a sharp focus, perhaps with the light somewhat shaded, will 
bring them into view quite clearly. In a highly alkaline urine they are 
indistinct, and after a time seem to become lost completely. 

2. Epithelial Casts (see Fig. 66). — True epithelial casts are hyaline 



TUBULAR CASTS. 163 

casts studded with epithelia. The desquamated epithelial tubes which 
are sometimes found in the urine, and represent solid masses of epithelia 
of varying length in the form of casts thrown off from the tubules, can 
hardly be called true casts, although they are usually classified as such. 

Epithelial casts, when present, always denote an acute process; and 
the more pronounced it is, the larger is the number of these casts. They 
vary in size according to their origin, but are never as long as some hya- 
line casts and are usually quite regular. They are of a higher refraction 
than the former, and can be easily found. The number of epithelia seen 
upon these casts varies considerably. Sometimes no more than two, 
three, or four will be found upon a cast, while at other times the cast is 
completely filled with them, though still showing its structure plainly. 
Those from the convoluted and narrow tubules contain spherical or 
slightly irregular epithelia, while those from the straight collecting tu- 
bules usually also contain a number of columnar epithelia. Occasionally 
these casts are of a yellowish color with a slightly increased refracting 
power, owing to their imbibition of the coloring matter of the blood. 

As long as the nephritis is acute, the epithelial casts will have the ap- 
pearance just described, being more or less coarsely granular, but with 
the epithelia perfectly intact. As soon as the inflammation enters the 
subacute or chronic stage, their character changes and fat-globules ap- 
pear. We can then no longer consider them pure epithelial casts. 

3. Blood Casts (see Fig. 67). — The presence of blood casts in the urine 
always shows a hemorrhage within the tubules of the kidney, and, when 
seen in large numbers, the complication is quite grave; but less so in 
children than in adults. The appearance of these casts varies greatly; 
they are usually more irregular than the epithelial casts, their ends more 
or less rounded, and they may be either studded with a varying number 
of red blood-corpuscles without changing their color, or, if they have been 
retained in the tubules for some time, the blood-corpuscles lose their 
shape, and the casts take on the appearance of dark, rust-brown, granu- 
lar clusters. 

Many of these casts may show transitional forms and are more or less 
distinctly colored. They always indicate an acute hemorrhagic process, 
and usually we find either hyaline or epithelial casts, or both, with them. 
Besides these, conglomerations of fibrin, the so-called fibrin casts, are oc- 
casionally found, but, properly speaking, they are not true casts. In the 
rare cases of hemoglobinuria, irregular, dark casts, which appear granu- 
lar and are composed of disintegrated blood corpuscles — the so-called 
haemoglobin casts — may be quite abundant. 

4. Granular Casts (see Fig. 68). — While the three varieties of casts 
just described are always found in acute cases or fresh acute exacerbations 



164 



URINARY ANALYSIS AND DIAGNOSIS. 



of chronic inflammations, granular casts rarely appear in strictly acute 
inflammations. As a rule, they are not formed until a number of weeks 
after the beginning of the disease; but in some cases, especially in chil- 
dren in whom a nephritis develops after contagious diseases, such as scar- 




Fig. 67. — Blood Casts (X 500). 

C, Casts from convoluted tubules; N, from narrow tubules; <S, from straight 

collecting tubules. 

let fever and diphtheria, they may be seen in small numbers one or two 
Weeks after the first symptoms of the nephritis have set in. 

Granular casts are either perfectly regular and have sharply defined 
contours, or they are more or less curved, or appear curved at one side 
while they are straight at the other. Their ends are either rounded or 
partly broken, and they may be broader at one place and narrower in 
another — a peculiarity especially pronounced in those from the narrow 



TUBULAR CASTS. 



165 



tubules. Their degree of refraction changes considerably, and they some- 
times appear yellowish, at other times colorless. 

The granulation of these casts varies to a great degree, some being 
coarsely granular, others finely granular, still others partly the former 
and partly the latter. They may appear coarsely granular at both ends, 




Fig. 68. — Granular Casts (X 500). 

C, Casts from convoluted tubules ; A r , from narrow tubules ; S, from straight 

collecting tubules. 

finely granular in the centre, or finely granular above and below and 
coarsely granular in the centre, the gradations being many. 

Granular casts are probably due in most cases to a disintegration of 
the kidney epithelia, which will commence after a varying length of time. 
In those cases which have not as yet become chronic, the disintegration 



166 



URINARY ANALYSIS AND DIAGNOSIS. 



of the epithelia can be studied under the microscope in all the different 
stages. In cases of long duration the granules become changed into 
glistening fat-granules and -globules. 

5. Fatty Casts (see* Fig. 69). — True fatty casts are always secondary 
products of epithelial and granular casts, therefore their size and shape 




Fig. 69. — Fatty Casts (X 500). 

C, Casts from convoluted tubules ; N, from narrow tubules ; aS, from straight 

collecting tubules. 

resemble the former considerably. The substance of all the casts so far 
mentioned is the same, the difference in appearance being given by the 
outer adhering formations. Conglomerations of variously sized, some- 
times large, fatty globules, without well-marked contours, showing their 
original substance, cannot be classed as true casts. 

Fatty casts contain a varying number of small, glistening fat-globules 



TUBULAR CASTS. 



16' 



and -granules, which give to the cast a high refraction, the cast being 
either completely or partially filled with them. As they are secondary 
products only, it follows that, even when they are present in small num- 
bers, the diagnosis of a chronic process is justified; the more so, the more 
completely they are formed. The commencement of their formation can 




Fig. 70.— Waxy Casts (X 500). 

C, Casts from convoluted tubules ; N, from narrow tubules ; S, from straight 

collecting tubules. 

frequently be seen in both epithelial and granular casts, the granules be- 
coming more glistening and highly refractive, and finally changing. to 
globules. When the casts are present in large numbers, they always de- 
note a pronounced fatty degeneration of the kidney, as found in the large 
white kidney. 

6. Waxy Casts (see Fig. 70). — Waxy casts are different in their chem- 



168 



URINARY ANALYSIS AND DIAGNOSIS. 



ical nature from hyaline casts; they are characterized by wavy, fluted 
contours, a high refracting power, a more or less yellowish color, and a 
high degree of brittleness. They vary greatly in size, and are always 
more or less irregular, on account of their frequently broken contours. 
Sometimes their wavy, fluted appearance is extremely pronounced, and 
they may resemble regular corkscrew windings. 




Fig. 71. — Mixed Casts (X 500). 



When all these characteristics are present the diagnosis of a waxy cast 
is plain, and such a cast never appears in acute inflammations, but only in 
chronic processes, which, if the casts are at all numerous, are always in- 
tense. They invariably signify waxy degeneration of the kidney. Some- 
times hyaline casts exhibit spiral windings, and may somewhat resemble 
waxy casts. These spiral windings are probably due to their having orig- 



TUBULAR CASTS. 169 

inated in the spiral portion of the ascending branch of the loop tubule, 
and have no special significance. Such hyaline casts are never of the 
same high refraction as the waxy casts, and a little care is sufficient to 
differentiate them from each other. 

Pure waxy casts may be found studded with different formations, 
which, of course, does not change the character of the cast. At times 
they are of extremely large size, and may then be almost entirely broken 
in different portions. 

7. Mixed Casts (see Fig. 71). — In a large number of cases, when casts 
are present, these casts do not appear in their true form, but may be 
more or less mixed. Any two, three, or four varieties may be so inter- 
mingled as to be difficult of differentiation. The more common of these 
forms will be found in Fig. 71. 

In the first row, the first cast shows an epithelial-granular-fatty vari- 
ety, with the epithelia perfectly intact; while the other casts partly show 
how the epithelia break down and become disintegrated into granules and 
fat-granules and -globules, partly the change of granular into fatty casts. 
The disintegration of the epithelia, in the manner here depicted, is fre- 
quently seen in subacute inflammations. The change of granular casts 
into the fatty kind is seen in chronic processes. 

In the second row, combinations of waxy casts are shown, the first 
being a fatty-w T axy; the second, a granular-fatty- waxy ; while the third 
and fourth are blood- waxy casts. The first cast in the third row is an 
epithelial-blood cast; the second, a blood-epithelial-granular-fatty cast; 
and the third, an epithelial-granular-fatty- waxy cast. The diagnosis of 
a case does not, of course, become altered by these combinations. 

Other Casts. — Besides these six varieties of casts, the mucus-casts or 
cylindroids, previously described, are occasionally placed among the true 
casts; that they do not have any special significance has already been 
stated. They may contain a varying number of fat-globules, but their 
striated, irregular appearance is sufficient to clear up the diagnosis. 

Again, a separate variety of casts is described as being derived from 
the seminal tubules. These casts are said to resemble hyaline casts, but 
to differ from them in their larger size, greater breadth, and greater irreg- 
ularity. They are, however, nothing but cylindroids, and, as such, have 
no special significance. 



170 



URINARY ANALYSIS AND DIAGNOSIS. 



II. FALSE OR PSEUDO-CASTS. 

False or pseudo-casts are not infrequently found in the urine, and 
have no connection whatever with diseases of the kidney. These forma- 
tions are mostly conglomerations of different substances upon mucus- 
threads or -casts, or accidental formations in the shape of casts. When 
true casts, especially of the hyaline variety, are present, together with an 
abundance of urates, the latter may undoubtedly be found upon the casts 
to such a degree as to render a diagnosis of the original cast doubtful. 

Urate Casts (see Fig. 72). — Among these formations, conglomerations 
of urates, sometimes called uric-acid casts — although uric acid, as such, 




Fig. 72. — Casts of Ammonium Urate and Sodium Urate (X 500). 



rarely enters into their structure — as well as casts of sodium urate, are 
not infrequently found. The former, consisting of conglomerations of 
ammonium urate, are described as occurring only in infants, and forming 
in them small, reddish-brown masses, apparent to the naked eye; but 
they are also seen in adults, although very rarely. Formations of sodium 
urate, resembling casts, may at times be mistaken for granular casts; but 



TUBULAR CASTS. 



171 



they have the characteristic yellowish-brown color of sodium urate, and 
show no outlines in many cases. When the masses of sodium urate are 
not heavy, mucus-threads or -strings can be distinctly seen underlying 
them. Besides these, we may also see such formations composed of gran- 
ules of sodium urate changing to globules and dumb-bells. When the 




Fig. 73. — False or Pseudo-casts (X 500). 
B, Bacterial casts; P, pus casts; Ft, fat cast; F, fibrin casts. 

change has advanced to a considerable degree, some of these formations 
may resemble disintegrated blood- or haemoglobin casts, and great care 
must be taken not to mistake such urate casts for blood casts. Here, 
too, the absence of a contour, as well as the color of the urates, will be 
sufficient for a diagnosis. 

Among the other pseudo-casts, the more common are bacterial, pus, 
fat, and fibrin casts (see Fig. 73) . 



172 URINARY ANALYSIS AND DIAGNOSIS. 

Bacterial Casts. — Bacterial casts are of frequent occurrence, especially 
when the urine has been allowed to stand in a warm room for twelve hours 
or more, so that a large number of bacteria have developed. They un- 
doubtedly resemble granular casts so much as sometimes to require a 
sharp focusing for their differentiation. They may vary considerably in 
size, but their outlines are pale and more or less irregular, and they are 
composed of masses of micrococci, not of granules. They have no signifi- 
cance whatever, except when found in perfectly fresh urine as an aid to 
diagnosis, where they are most likely to be seen in severe inflammatory 
or suppurative processes. As a rule, the micrococci become deposited 
upon mucus-threads. In order to clear up their diagnosis, it may, in rare 
cases, be necessary to add a drop or two of some strong mineral acid or 
alkali, to which they will be seen to have a great resistance. 

Pus Casts. — Pus casts — that is, cast-like conglomerations of pus-cor- 
puscles, usually upon mucus — are found in some cases. The pus-corpus- 
cles may be massed together, with no outlines visible, or they are more 
loosely arranged, and may contain a number of small fat-globules. Pus- 
corpuscles may, of course, be found in small numbers upon different true 
casts, such as hyaline or epithelial, but such formations cannot be classed 
as pus casts. 

Fat Casts. — Pseudo-fat casts are rare, but have been found in a few 
cases of so-called lipuria. They consist of large fat-globules, of a very 
high refraction, and occasionally containing margaric-acid needles. Again, 
a number of extraneous fat-globules upon mucus-threads have been seen; 
but these have a yellowish color, and can easily be differentiated. 

Fibrin Casts. — Lastly, fibrin casts may be found in cases of hemor- 
rhage. They may be of large size, have irregular, more or less sharply 
defined contours, and are of a yellowish or yellowish-brown color. They 
consist of small, wavy, irregular fibres, and never occur without the pres- 
ence of characteristic strings or bands of fibrin. In cases of hemorrhagic 
parenchymatous nephritis, true blood casts are always associated with 
them. 

Besides haemoglobin, which may occur in the form of casts, two other 
varieties of pseudo-casts have been described, namely, pigment and cho- 
lesterin casts. Peyer has seen one specimen of each of these, but they 
are the rarest formations in urine. 



CHAPTER XIV. 

MICRO-ORGANISMS AND ANIMAL PARASITES. 
I. MICRO-ORGANISMS, OR FUNGI. 

Perfectly fresh urine normally does not contain any micro-organ- 
isms and can be considered sterile when obtained directly from the bladder; 
it may, however, be contaminated, when voided, by bacteria present in 
the urethra and especially the vagina. When allowed to stand, bacteria 
usually develop in a short time, even in originally sterile urine. In 
pathological conditions, on the other hand, bacteria may be present in 
large numbers when voided; such urine is always more or less turbid, 
and here the designation bacteriuria can be used. 

The development of bacteria in urine may be slow or rapid, depending 
partly upon the reaction and partly upon the temperature. In an alka- 
line urine they develop rapidly, and in a warm temperature are usually 
found in large numbers one or two hours after the urine is voided. 
Bacteria present when the urine is passed may be derived from any 
portion of the genito-urinary tract or may be transported through the 
blood stream. 

Micro-organisms seen in urine are divided into non-pathogenic and 
pathogenic. The former may belong to either the class of mould fungi, 
to that of yeast fungi, or to that of fission fungi; while the latter belong 
to the class of fission fungi. 

Non-pathogenic Micro-organisms. 1. Mould Fungi. — Mould fungi, or 
hyphomycetes, found in urine are either oidium, penicillium glaucum, or 
one of the aspergilli, the latter being comparatively rare. These fungi 
will be seen only in acid urine, or urine which was originally acid, even 
though it has become alkaline. 

The most common of the hyphomycetes is the oidium lactis, com- 
posed of conidia and mycelia (see Fig. 74). It easily develops in small 
numbers in urine of a highly acicl reaction, and can be seen with the 
naked eye, in the form of whitish masses, only when present in large 
amount. Such urines contain a varying number of small globules, in 
which frequently a central so-called vacuole is observed, together with 
threads of mycelia, either narrow and short, or quite large and branching. 
The globules are the spores or conidia, and care must be taken not to 

173 



174 



URINARY ANALYSIS AND DIAGNOSIS. 



mistake them for red blood-corpuscles or even fat-globules, which they 
may resemble. They vary in size, and can generally be distinguished by 
the central vacuole. The threads are the mycelia, which are, as a rule, 
coarsely granular and segmented, and contain a number of spores. They 




Fig. 74. — Oidium Lactis (X 500). 



may be mistaken for mucus, connective tissue, or even granular casts 
from the narrow tubules, from all of which they differ, however, by their 
peculiar, rather high refraction. 

Besides the oidium lactis, both the penicillium glaucum and different 
varieties of aspergilli may be found in the urine, the former being quite 
common (see Fig. 75). The diagnosis of penicillium or aspergillus can be 
made only by the characteristic fruit-bearer or sporangium arising from 
the hypha. In penicillium glaucum, the most common mould fungus, the 
hyphae divide and subdivide into thread-like formations — the basidia and 
sterigmata — the ends of which latter are surmounted by a number of 
spores or conidia. In the aspergilli no division takes place, but the hypha 
terminates in a spherical or club-shaped vesicle, from the periphery of 
which a number of short flask-like formations — the sterigmata — are vis- 
ible, each of which contains a single spore upon its upper end. 

2. Yeast Fungi (see Fig. 76). — The yeast fungi, or saccharomycetes, are 
found in acid urine, and are most frequently seen in those containing 
sugar, where they may be present in large numbers. They consist of va- 



MICRO-ORGANISMS AND ANIMAL PARASITES. 175 

riously sized globules or cells, the larger of which contain a smaller glob- 
ule or nucleus. They never form mycelia, but multiply by sprouting or 
budding. The globules have an oval or round shape, lie either singly, in 
twos, or in groups of different sizes, and are frequently beaded. In the 




Fig. 75. — Penicillium Glatjcum and Aspergilli (X 500). 

The upper half of the drawing shows the penicillium glaucum, the lower half different 

varieties of aspergilli found in urine. 

larger globules the process of budding can be plainly seen. The smaller 
globule, or daughter-cell, sprouts out from the larger or mother-cell, be- 
comes an independent formation, grows, and, in its turn, forms a mother- 
cell. These globules may undoubtedly resemble blood-corpuscles, but 



176 URINARY ANALYSIS AND DIAGNOSIS. 

their irregular size and shape, together with the presence of the nucleus, 
will be sufficient to differentiate them. 

3. Fission Fungi (see Fig. 77). — The fission fungi, or schizomycetes, are 
rarely seen in highly acid urine, but frequently in urine which is becom- 
ing alkaline or has already undergone an alkaline change and is showing 




Fig. 76.— Saccharomycetes (X 500). 

putrefaction. When they are present in large numbers the urine is always 
cloudy, and both cocci and bacilli may be found. Of the former, the most 
numerous are large cocci, lying either irregularly or in small chain form — 
the micrococcus urece. This coccus, to a great degree, causes ammoniacal 
decomposition of the urine, the urea being transformed by it into ammo- 
nium carbonate. In urines containing pus-corpuscles in large numbers, 
both staphylococci and streptococci pyogenes — the former being small cocci 
grouped in variously sized, irregular bunches, and the latter in longer or 
shorter chains — will also be seen. Besides these, the so-called zooglcea 
groups of cocci — cocci arranged in more or less regular masses — envel- 
oped in a colorless, gelatinous capsule, may also be found, as well as large 
cocci, the sarcince urince, which are united into packets resembling corded 
bales of cotton, and are usually smaller than the sarcinse found in sputa. 
Staphylococci and streptococci pyogenes are pathogenic, and may be 
found in any inflammatory condition. 

Bacilli are usually present in varying numbers with the cocci, and are 
of different sizes, some of the small ones occasionally lying in twos, being 
formerly called bacterium termo, one of the varieties of putrefactive bacilli 
which cause ammoniacal decomposition of urine. Others, among them 
the bacillus or bacterium urece, are larger, and there are still others larger 



MICRO-ORGANISMS AND ANIMAL PARASITES. 177 

than the latter, among which the bacillus subtilis, or hay bacillus, is com- 
mon. These bacilli are found to have a varying amount of motion, some 
being very active, others only slightly movable, and some without motion. 
Besides the single bacilli, the urine not infrequently contains threads, 
composed of individual rods — the leptothrix threads — which may be 
quite abundant. There are cases of chronic cystitis, in which the urine, 
when voided, contains leptothrix threads in large numbers, and in which 
the cystitis seems to be caused by the leptothrix; these threads may lie 
upon as well as between the epithelia. In such cases whitish masses of 
small size are found in the freshly voided, cloudy urine, and when exam- 
ined under the microscope are seen to consist of conglomerations of blad- 
der epithelia with many leptothrix threads. Cases of this kind may last 
for many years, and frequently recur in spite of all local treatment. 







B-r^d^ 




-Ml/ 



''"■-IS . "f 

~. ', : - ~ --" j 

- •■■:-: i---'~i;S?-x--37 

- >*■-/, 

Fig. 77. — Schizomycetes (X 500). 
B, Bacilli; St, streptococci; Sa, staphylococci ; L, leptothrix; MU, Micrococcus urese; 
Z, zooglcea; S, sarcinse. 




Pathogenic Schizomycetes. — Among the pathogenic bacteria, the 
most important are undoubtedly the gonococci and tubercle bacilli, which 
are not infrequently found in urine, and for which careful search must, 
when necessary, be made. For the detection of these, it will always be 
necessary to color the specimens, and the mode of procedure is the fol- 
lowing: Select the thickest portion of the urinary sediment, best ob- 
tained by the use of the centrifuge, or the filaments, if any are present, 
as will be the case in chronic gonorrhoea, and by means of a sterilized 

12 



178 URINARY ANALYSIS AND DIAGNOSIS. 

needle spread carefully over perfectly clean cover glasses, taking never 
less than two, but preferably three or more. Allow the glasses to dry 
thoroughly, and draw them through the flame of an alcohol lamp or a 
Bunsen burner in a moderately quick manner, specimen side upward, 
three times, partly to fix the specimen upon the cover glass, and partly 
to coagulate the albuminous substances present. Then color the speci- 
men with an aniline color, either fuchsin, methylene blue, or gentian 
violet. 

Gonococci. — In searching for gonoccoci in the urine, the cover glasses 
are best colored, for a few seconds to one or two minutes, either with a 
plain watery fuchsin solution, made by taking one part of a concen- 
trated alcoholic fuchsin solution (one part of fuchsin in substance to four 
or five of absolute alcohol) to eight, ten, or twelve parts of distilled water; 
or with a methylene-blue solution — fifty to sixty drops of a concen- 
trated alcoholic solution (one part of methylene blue to four or five of 
absolute alcohol) to one ounce of water. Methylene-blue solution may 
also be made by taking 30 c.c. of a concentrated alcoholic methylene- 
blue solution and 100 c.c. of 0.01 per cent caustic potash; this is 
Loeffler's alkaline methylene-blue solution. Any one of these solu- 
tions, if carefully made, will keep a long time, and is always ready for 
use. 

After having passed the cover glasses through the flame, as just de- 
scribed, a small amount of the coloring solution is dropped upon the 
specimen and allowed to remain for from a few seconds to a minute or 
two, the former being sufficient when fuchsin is used, the latter being 
necessary when methylene blue is employed. After coloring, the cover 
glass is rinsed in water, the lower surface dried, and the specimen either 
at once mounted upon a slide and examined in water or dried and mount- 
ed in a drop of Canada balsam. 

In searching for gonococci, it is always best to use an immersion 
lense and a magnifying power of 900 or 1,000 diameters, although a 
power of 700 or 800 diameters is sufficient. In specimens so prepared, 
the gonococci, as well as the nuclei of the pus-corpuscles and epithelia, 
are colored. The pus-corpuscles contain one or more nuclei. 

In cases of acute gonorrhoea (see Fig. 78) the gonococci, or micrococci 
gonorrh&ce, are found in large numbers in the urine, not as numerous as 
in the gonorrhceal pus taken directly from the orifice of the urethra, but 
still very abundant. They are seen both in the pus-corpuscles and lying 
free in variously sized groups. The pus-corpuscles are numerous, and mu- 
cus-threads in small numbers are always present. Urethral epithelia are 
also usually found, and may contain groups of gonococci. 

Gonococci were first discovered by Neisser in the year 1879, and cul- 



MICRO-ORGANISMS AXD ANIMAL PARASITES. 179 

tivated by Bumm in 1885. They are, as a rule, found in twos, either sin- 
gly or in groups, with the adjacent surfaces flattened and separated by a 
colorless interspace, giving the so-called biscuit shape. The more or less 
regular groups of diplococci are found either entirely within the pus cor- 
puscles or epithelia, or lying entirely free, but never half-way within and 
half-way free, though large groups, completely filling the pus-corpuscles, 
may slightly overlap the periphery. Again, no matter how completely 
the pus-corpuscles are filled with them, the nucleus or nuclei usually re- 

@#@© ® © ® 



®. "SLOTS® 











Fig. 78. — Acute Gonorrhoea ( X 700). 
G, Groups of gonococci; GP, pus-corpuscle containing gonococci; MS, mucus-thread. 



main free, though here, again, individual cocci may be found upon the 
periphery of the nucleus. These features, though perhaps not absolutely 
characteristic, are sufficiently so for all practical purposes. 

If any doubt remains about their character, Gram's method should 
be used. Color a few specimens with gentian violet, either a carbolic 
solution made by taking 10 parts of a saturated alcoholic solution of 
gentian violet and 90 parts of a five per cent watery carbolic acid, or an 
aniline solution, made by adding 5 parts of a concentrated alcoholic 
solution to 100 parts of aniline water (aniline oil 1 part, distilled water 
20 parts, and filter) for a few minutes and subject to Gram's solution 
(pure iodine 1 part, iodide of potash 2 parts, and distilled water 300 
parts) for one or two minutes. The specimens are now washed in alco- 
hol, then rinsed in water and recolored with a one or two per cent 



180 



URINARY ANALYSIS AND DIAGNOSIS. 



aqueous solution of Bismarck brown for one-half to one minute, again 
rinsed in water, dried and examined. Gonococci are Gram-negative. 
When subjected to this method, the gonococci have lost their origi- 
nal violet stain and have taken up the Bismarck brown, being, there- 
fore, colored brown. This method at once differentiates them from the 
staphylococci, which retain their violet color. If all the features enu- 
merated, especially their characteristic grouping within the pus-cor- 
puscles, and the loss of their violet color by the last-named method, are 
present, no doubt whatever will exist as to the character of the cocci. 
In acute cases of gonorrhoea the search for gonococci is very easy; but 
this becomes a more difficult matter in the chronic cases, where only a 







Fig. 79. — Chronic Gonorrhoea (X 700). 
GP, Pus-corpuscles containing gonococci; GE, epithelium from the prostate gland 
containing gonococci; St, pus-corpuscles containing Staphylococci pyogenes; Sr, Strep- 
tococci pyogenes ; MU, Micrococcus urea; ; MS, mucus-threads; MP, mucus-corpuscle. 



small number of filaments may be found in the urine. Frequently it is of 
the utmost importance to determine the presence or absence of gonococci 
in such cases, and the filaments are subjected to the methods just described 
and carefully examined. As before said it is never advisable to depend 
upon a power of 500 diameters, but higher powers, preferably a homo- 
geneous immersion lens, should be used, and a large number of speci- 
mens carefully examined. The features found in such a filament, con- 
taining gonococci, are shown in Fig. 79. 



MICRO-ORGANISMS AND ANIMAL PARASITES. 181 

Pus-corpuscles are never so abundant in these cases as in the acute, 
and may even be quite scanty, but mucus-threads as well as corpuscles 
are numerous; epithelia from the urethra, and usually from the prostate 
gland, will also be seen. The gonococci are always found in smaller num- 
bers, but only singly or in small groups, and the cocci seen should never 
be diagnosed as such unless some are found within the pus-corpuscles. 
Besides gonococci, such filaments always contain irregular groups of 
staphylococci; these may be either free or in groups, lying partly within 
pus-corpuscles and partly outside. In some cases streptococci, usually in 
rather small chains, are also present, as well as the micrococcus ureas in 
chains or irregular small groups. 

Occasionally it may be necessary to use culture media, although it is 
difficult to grow gonococci from urinary sediments. For this purpose either 
blood-serum agar or Loeffler's blood serum may be used, though some 
prefer media made with hydrocele or ascitic fluid and agar-agar. Even 
at best the growth of gonococci is slow and never very heavy. 

Other Cocci. — Besides gonococci, other pyogenic cocci, both staphylo- 
cocci pyogenes and streptococci pyogenes, are found in urine, but, as 
may be expected, only wherever there are large numbers of pus-corpus- 
cles; they, therefore have little practical significance. The staphylo- 
cocci are the staphylococcus pyogenes aureus, albus, and citreus, which 
can be differentiated only by culture methods. Besides the streptococ- 
cus pyogenes, a streptococcus, which cannot be distinguished from it, but 
has been described by Fehleisen as being the cause of erysipelas, may be 
found in all cases of erysipelas in which a nephritis is at the same time 
present. Micrococci have also been seen in the urine in septic processes, 
as well as in endocarditis. 

Tubercle Bacilli. — The presence of tubercle bacilli in moderate num- 
bers in the urine is always a symptom of tuberculosis somewhere in the 
genito-urinary tract. Its exact location can easily be determined by the 
characteristic epithelia. As a rule, they will be found in larger numbers 
only when a suppurative or an ulcerative process exists; and whenever 
the diagnosis of a suppuration or an ulceration can be made from the dif- 
ferent features found in the urine, especially with all the evidences of 
a chronic condition, it will be best to examine for tubercle bacilli even 
though distinct clinical symptoms of a tubercular process have not 
as yet developed. 

The search for tubercle bacilli in the urine is by no means an easy one; 
many drops may have to be examined before arriving at a definite con- 
clusion. The appearance of the urine is no criterion, since bacilli may be 
present in small numbers in rather clear urine, though, as a rule, it will be 
more or less turbid. They can be found in either an acid, amphoteric 



182 URINARY ANALYSIS AND DIAGNOSIS. 

or alkaline urine, but the presence of a large number of salts renders 
their detection still more difficult. In such cases it is advisable to dis- 
solve the salts with a solution composed of 1 part of borax, 1 part of boric 
acid, and 25 parts of water, which is simply added to the sediment. 

When a urine is to be examined for tubercle bacilli it should be fresh 
and, preferably, it should be obtained by catheter after thoroughly 
cleansing the external genital organs, to prevent the admixture as much 
as possible of putrefactive microorganisms, and especially of the 
smegma bacillus. The latter, like the tubercle bacillus, is an acid- 
fast microorganism, resembling the tubercle bacillus to a considerable 
degree, and is not infrequently present on the external genitals of both 
sexes. The fresh urine, which should, if possible, be placed in a sterile 
bottle, is now allowed to stand in a cold place for six hours, so that 
a sediment forms by gravity; the supernatant fluid is then carefully 
decanted, the sediment put in the centrifuge tubes and centrifugalized 
for three minutes. Of the sediment obtained in this manner, the thick- 
est portion is selected and a number of smears made upon perfectly 
clean slides or cover glasses. After they are perfectly dry, they are 
fixed by passing them through the flame of a Bunsen burner or an 
alcohol lamp three times, specimen side upward. Specimens obtained 
in this manner by double sedimentation, that is gravity and the cen- 
trifuge, give better results than when the urine is centrifugalized at once. 
Ellerman and Erlandsen* allow the catheterized urine to settle, 
decant the supernatant fluid, centrifugalize, mix the sediment thus ob- 
tained with four times its bulk of a 0.25 per cent solution of sodium 
carbonate, and place it in the incubator for twenty-four hours at 37° C. 
(98|° F.). If the reaction is still acid, they add a little more sodium 
carbonate and allow the digestion to continue somewhat longer. They 
now decant the upper layer of the supernatant fluid and centrifugalize 
the remainder. To the sediment left then, after pouring off the upper 
fluid, they add four times its volume of a 0.25 per cent solution of 
sodium hydroxide and stir with a glass rod till dissolved. The whole 
is then heated to boiling over the water bath; after cooling it is once 
more centrifugalized, and the sediment thus obtained is used for stain- 
ing. This somewhat complicated method is, as a rule, unnecessary, 
but in those cases in which the clinical symptoms point to a tubercular 
process in the genito-urinary tract, and tubercle bacilli can not be found 
by the simple methods of sedimentation, it possesses its advantages. 
Small numbers of tubercle bacilli can not infrequently be found by this 
method, after other means have failed. 

The staining methods employed for detecting tubercle bacilli are 
* Journ. of Am. Med. Assoc, Sept. 19, 1908. 



MICRO-ORGANISMS AXD ANIMAL PARASITES. 183 

numerous, but the simplest and best is theZiehl-Xeelsen carbol-fuehsin 
method. The staining solutions' necessary are. first, a 'carbolic acid 
fuchsin solution, prepared by dissolving 1 gm. of fuchsia* in 10 c.c. 
of absolute alcohol and adding 90 c.c. of a five per cent aqueous carbolic 
acid solution; and second, Loefner's methylene blue solution, made by 
taking 30 c.c. of a saturated alcoholic solution of methylene blue and 
100 c.c. of a 0.01 per cent aqueous solution of caustic potash. The 
dried and fixed smear is covered with the carbol-fuehsin and heated, 
until it steams, over an alcohol flame or a Bunsen burner: the warm 
specimen is then set aside for from five to ten minutes, at the end of 
which time the tubercle bacilli are stained. It is not a good plan to boil 
the solution upon the smear over the flame for one or two minutes, as 
was formerly advised, since the specimen decolorizes less rapidly than 
by simple steaming. If a number of specimens are to be stained at 
once, it is best to make cover glass smears, float these in a watch glass 
filled with the fuchsin solution, specimen side down, heat for a few 
mimites to steaming, but not to boiling, and leave the specimens in the 
warm solution for a few minutes longer. Instead of warming the solu- 
tion, a cold solution may be used, but then it is necessary to stain the 
specimens for about two hours instead of five to ten minutes. 

Anilme-fuchsin may be used instead of carbol-fuehsin; this is made 
by adding enough of a concentrated alcoholic fuchsin solution (1 part of 
fuchsin to 5 parts of absolute alcohol I to aniline water (1 part of aniline 
oil to 20 parts of distilled water and filter) until saturation takes place; 
that is, until a distinct film appears at the top of the solution: this is 
usually one part of the alcoholic solution to eight or ten of aniline water. 
This solution, however, does not keep well and staining with it is slower, 
though the method, originally employed by Koch, is an excellent one; 
about twenty minutes are required for staining with the warm solution. 

After the specimens are stained they must be decolorized. The 
tubercle bacilli stain slowly, but are then not readily decolorized, being 
both acid-fast and alcohol-fast, in contradistinction to most other bac- 
teria, which will quickly lose their color when subjected to the action 
of acids and alcohol. Different acids maybe used for decolorizing, bu^ 
one of the best is a twenty to twenty-five per cent aqueous solution of 
nitric acid. The procedure is the following: After being stained, de- 
colorize the smears with the nitric acid for a few seconds only, then 
thoroughly wash in a sixty per cent solution of alcohol until all color 
has disappeared, place specimen in absolute alcohol for a few minutes, 
wash in water, and at once recolor for about one-half minute with 
methylene blue, again wash in water, dry and specimen is ready for 

* Acid fuchsin must not be used for tubercle staining. 



184 



URINARY ANALYSIS AND DIAGNOSIS. 



examination. If cover glasses have been used for making the smear, 
mount upon a slide with a drop of Canada balsam. Instead of nitric 
acid a ten per cent solution of sulphuric acid in alcohol may be used, and 
the decolorizing agent allowed to act until the specimen is practically 
decolorized, when it is washed in water and restained ; or a two or three 
per cent alcoholic solution of hydrochloric acid may be used. Gabbett's 
method of using a sulphuric acid-methylene blue solution (methylene 
blue powder 1 or 2 parts, 25 per cent sulphuric acid 100 parts) thus 
decolorizing and counter staining at the same time, is not advisable 
in urine work. 

In specimens prepared in this manner, the tubercle bacilli, if any are 
present, are seen as bright red rods of varying lengths, either single, in 




Fig. 80. — Tuberculosis of the Kidney (X 650). 
TB, Tubercle bacilli ; PC, pus-corpuscle ; CE, epithelium from convoluted tubules of 
kidney; PE, epithelium from pelvis of kidney; MS, mucus- threads ; MC, mucus-cor- 
puscle. 

twos forming acute angles or crossed, or in groups, partly straight, 
partly bent or curved and occasionally showing branching forms; not 
infrequently they appear beaded, giving the appearance of a number of 
cocci joined together. Their number in urine varies greatly; some- 
times they are so scanty that two or three specimens have to be ex- 
amined before any are found, at other times they are so numerous that 
every field contains them, and they may be seen in clumps containing 
ten, twenty, thirty, or considerably more, bacilli. All the other fea- 
tures are colored blue. 

A specimen of tuberculosis of the kidney, colored in this manner, is 



MICRO-ORGANISMS AND ANIMAL PARASITES. 185 

shown in Fig. 80. The features which can easily be recognized are 
tubercle bacilli in moderate numbers, pus-corpuscles, epithelia from the 
convoluted tubules of the kidney, epithelia from the pelvis of the kid- 
ney, mucus-threads, mucus-corpuscles, and various cocci. 

Care must be taken not to mistake the harmless smegma bacillus, 
which is frequently present in the urine, resembles the tubercle bacillus, 
and is also resistant toward acids, for the tubercle bacillus. The 
smegma bacillus, however, does not resist absolute alcohol for any 
length of time, so that, when its presence cannot be excluded, it is best 
to subject the specimen for ten to twenty minutes to alcohol after 
being treated with the acid. The tubercle bacillus is not affected by 
the alcohol. 



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Fig. 81. — Bacillus Coli Communis (X 600) 



In doubtful cases animal inoculations must be made, a small amount 
of the sediment being injected into the abdominal cavity of a guinea- 
pig. If the sediment contained tubercle bacilli, tuberculosis will de- 
velop in the animal in from three to five weeks. The cultivation of 
tubercle bacilli from the urinary sediment does not give satisfactory 
results. The use of tuberculin injections to determine the presence or 
absence of tuberculosis is also recommended. 

Typhoid Bacilli. — Among the other pathogenic bacilli found in 
urine, the typhoid bacilli have been discovered in large numbers in cases 
of typhoid fever, though never at the commencement of the disease, and 
they are not, therefore, of much practical value for the diagnosis. 
Poniklo, in the year 1892, was the first to call attention to the presence 
of typhoid bacilli in the urine, and since then the bacilli have been found 



186 



URINARY ANALYSIS AND DIAGNOSIS. 



by different observers. In most cases described, the evidences of a 
more or less pronounced nephritis or of a hemorrhage were also present. 
The bacilli may persist in the urine for weeks and even months, and 
may be extremely abundant. 

Bacillus Coli Communis. — The bacillus coli communis (see Fig. 81) is 
not infrequently present in urine, especially in pronounced inflamma- 
tions, such as nephritis, pyelitis, and cystitis; it may be found in large 
numbers, and seems to be a rather common cause of cystitis. This 
bacterium is a short, thick. rod, found also in twos, small chains, and 
groups. It has a moderately active motion. In the year 1895 Pluym 
and Laag described it as the sole cause of a urethritis which gave all the 
symptoms of a gonorrhceal infection, in which gonococci were entirely 




Fig. 82. — Actinomyces ( X 500). 



absent, but the bacillus coli communis was found in large numbers, 
lying mostly within the pus-corpuscles and epithelia. 

Other bacilli have also been described as being present in various 
diseases of the genito-urinary tract, but they are of no diagnostic value. 

Actinomyces. — The fungus known as actinomyces (see Fig. 82) is of 
rare occurrence in the urine, but is undoubtedly found in actinomycosis 
of the internal organs, where the disease affects the genito-urinary 
tract. Its classification is still undecided, but it seems to stand in an 
intermediate position between the bacteria and the higher fungi. 

The fungus consists of variously sized conglomerations of highly re- 
fractive, irregular, club-shaped masses. The club-shaped, cylindrical, or 



MICRO-ORGANISMS AND ANIMAL PARASITES. 187 

pear-shaped masses terminate toward the centre in a point or fibrilla, 
which loses itself in a mass of granules, amid other similar fibrillse. The 
individual club-shaped elements greatly vary in length, but all terminate 
in the centre. 

The urine from which the accompanying drawing was made was tur- 
bid when passed and gave all the macroscopical evidences of a chronic 
cystitis. It contained a few small granular masses which proved to be 
actinomyces. The features present under the microscope were numer- 
ous, and conclusively showed a chronic ulcerative process in the bladder. 
There were pus-corpuscles in large numbers ; epithelia from the bladder, 
especially cuboidal and columnar; numerous connective- tissue shreds; 
fat-granules and -globules; large zooglcea masses; mucus- threads and 
-corpuscles, and the actinomyces fungus, which was perfectly characteris- 
tic, so that the diagnosis of a chronic ulceration of the bladder, due to 
actinomyces, could easily be made. The reaction of the urine was alka- 
line. 

II. ANIMAL PARASITES, OR ENTOZOA. 

Trichomonas Vaginalis (see Fig. 83). — Of all the animal parasites, the 
most common is the trichomonas vaginalis, which belongs to the class of 
flagellata. It occurs in the urine of females, being a frequent but per- 




Fig. 83. — Trichomonas Vaginalis (X 500). 



fectly harmless inhabitant of the mucosa of the vagina in cases of leucor- 
rhcea. Although it has no pathological significance, its occurrence and 



188 



URINARY ANALYSIS AND DIAGNOSIS. 



shapes must be known, since it otherwise might be mistaken for different 
formations, especially when small. 

Trichomonas is of an oval or somewhat irregular form, and usually has 
a tail-like extremity. This extremity, mostly of the same size as the body 
or a little longer, may occasionally be three or four times that size, of con- 




Fig. 84. — Portions of Echixococcus (X 400). 



siderable thickness, and striated. It may, however, be nothing but a 
small filament, like a flagellum. In the interior of the body one, two, or 
more small formations, similar to nuclei, may be seen. In many cases one 
or more cilia are given off from one extremity or side. 

Echinococci (see Fig. 84) . — These entozoa, although rare, do occasion- 
ally occur in the urine, and may either have developed directly from the 
urinary organs or have ruptured from some neighboring organ. The 
characteristic parts of the echinococci found in the urine are the hooklets 
as well as portions of the membrane; scolices may also be found. 

The echinococci cysts, as such, will never be seen in the urine, and in 
a suspected case it may become quite difficult to find the characteristic 
portions. The scolices are small, usually round, and supplied with a 
wreath of hooklets. The individual hooklets do not vary in size to a great 
degree, and their shapes, although differing somewhat, are more or less 
identical. Parts of the membrane which have a concentric striation may 
at times be present. In the specimen from which the illustration was 



MICRO-ORGANISMS AND ANIMAL PARASITES. 189 

taken, the different portions here shown could be found only after pa- 
tient search, but were characteristic. 

In all cases in which parts of the echinococci are found in the urine, 
evidences of a hemorrhage or an ulceration, or both, will be present. As 
a rule, red blood-corpuscles are numerous, together with epithelia and 




Fig. 85. — Ova of Distoma Haematobium (X 500). 



connective-tissue shreds from the organ in which the cysts are located. 
Pus-corpuscles are usually abundant. When the echinococci have directly 
developed in the urinary organs, the kidney is the general location, and 
epithelia from both the convoluted and straight collecting tubules are 
present. 

Distoma Haematobium (see Fig. 85). — The parasite distoma haemato- 
bium, or Bilharzia haematobia. so called from Bilharz, who first described 
it, has probably never been found in the urine, but its eggs do occur in 
some cases. It is common in tropical countries, especially in Egypt, 
and is found in the portal vein and its branches, the splenic and mesen- 
teric veins, as well as in the venous plexuses of the rectum and bladder. 

In our climate Bilharziasis is rarely found, but does occur. It may 
be seen in persons who have recently returned from the tropics, and the 
ova may be found in the urine in considerable numbers. The illustra- 
tion was taken from such a case, and in every drop examined a dozen or 
more of the ova were present. They have an oval or flask-like shape, 
are large, and taper considerably at one extremity, the other being 
rounded. They consist of a moderately thick, highly refractive cap- 
sule, are coarsely granular, and contain quite a number of small, round- 
ish, granular bodies within a membranous formation. 

When these ova are found in the urine, blood-corpuscles, pus-corpus- 
cles, and epithelia, usually from the bladder, are seen, showing a hemor- 



190 



URINARY ANALYSIS AND DIAGNOSIS. 



rhage or inflammation of the bladder. In most cases fat-globules and 
-granules are also present in considerable numbers. The parasites may 
invade any portion of the urinary tract, especially the ureters and pelves. 
Filar ia Sanguinis Hominis (see Fig. 86). — This parasite is also of rare 
occurrence in our climate, but common in other climates, as in the West 
India Islands, Egypt, China, and Japan. It seems to be transferred to 
human beings through mosquito bites, and may be extremely abundant 
in the blood; in urine it may be found in varying numbers in such cases. 




Fig. 86. — Filaria Sanguinis Hominis (X 600). 



It consists of a cylindrically shaped body, a short, rounded head, and a 
long, thread-like, pointed tail. It is granular and frequently striated. 

When the parasite appears in the urine, it may cause either severe 
hematuria or the condition known as chyluria, or more frequently both. 



MICRO-ORGANISMS AND ANIMAL PARASITES. 191 

It is claimed that it may be present in perfectly clear urine, but this must 
be very rare, since, as a rule, the urine presents a milky appearance when 
voided, and upon examination is found to contain a large amount of fat, 
in the form of small globules and granules, as well as the evidence of a 
more or less pronounced hemorrhage. Pus-corpuscles, as well as different 
epithelia, are usually present in small numbers. 

When such a milky urine, denoting chyluria, is examined, filaria must 
always be looked for, since the parasite is almost invariably the cause of 
this condition. It may be present in large numbers in the urine, so that 
there will be no difficulty in finding it; but, on the other hand, it may be 
scanty. In examining for filaria, it is advisable to take the first urine 
voided in the morning, since it is a well-known fact that the parasite is 




Fig. 87. — Ova and Portion of Ascaris Lumbricoides (X 500). 

active at night, or rather during the resting hours of the patient, and can 
then be found in large numbers in the blood, while it is quiescent during 
the working hours and cannot be found. 

Ascaris Lumbricoides (see Fig. 87). — Although in rare instances only, 
the round worm, ascaris lumbricoides, of such common occurrence in the 
intestinal tract of children, may be found in the urine, having passed into 
the bladder through the urethra. Portions of the parasite and a number 
of ova will then be present in the urine. 

The urine from which the illustration was taken gave all the features 
of a severe acute catarrhal cystitis. It contained a small number of mi- 
nute particles, which proved to be the ova ; also a part of the body of an 
ascaris. The ova, of a yellowish-brown color, are round formations, en- 
closed in a thin, irregular capsule and a somewhat thicker membrane; 



192 URINARY ANALYSIS AND DIAGNOSIS. 

the interior is coarsely granular and contains a nucleus. The parasite 
itself is of considerable size, has a cylindrical body, a narrower, tail-like 
extremity, and a head consisting of three papilliform nodules ; it is found 
in the urine only in very rare instances. 

Other Parasites. — Other parasites which may possibly be found in the 
urine are the strongylus gigas, oxyuris vermicularis , and the cercomonas 
urinarius. The strongylus gigas resembles the ascaris lumbricoides, al- 
though it is much larger, and its head contains six papilliform nodules 
instead of three. The oxyuris vermicularis is a small, thread-like forma- 
tion, and the cercomonas urinarius a small flagellate, which consists of 
an oval, granular body, and contains a number of flagella. These 
parasites are rare and of little practical importance. The oxyuris 
vermicularis, the pin- or seat-worm, however, may migrate into the 
urethra, especially of females, exceptionally of males, causing a more or 
less pronounced irritation. 



CHAPTER XV. 

EXTRANEOUS MATTERS. 



Extraneous matters are common occurrences in urinary sediments, 
and must be well known, as they might frequently lead to errors in diag- 
nosis. Their presence in the sediment may be due to many causes, such 
as exposure to air, from which various objects may fall into the urine, 
pouring the urine into bottles which are not perfectly clean, the use of 
salves or dusting-powders for the genital organs, or admixture of particles 




Fig. 88. — Cotton Fibres (X 500). 

from the faeces. Many of these formations are characteristic enough, but 
others may closely resemble various features of normal or pathological 
urine, from which they must be carefully differentiated. 

The different fibres of cotton, linen, silk, and wool are frequently 
found in the urine. 

Cotton Fibres (see Fig. 88). — Cotton fibres are coarse, somewhat wavy 
and twisted. They are highly refractive, their edges being more compact 
than the centre. The central portion may appear slightly folded, and 
13 193 



194 URINARY ANALYSIS AND DIAGNOSIS. 

often shows irregular markings. When the fibres are very small, the 
diagnosis must be made from the wavy, compact appearance. 

Linen Fibres (see Fig. 89). — Linen fibres are variously sized, some- 
times broad, and at other times narrow. They are composed of smaller 




Fig. 89.— Linen Fibres (X 500). 

fibrillaB, which, although quite refractive, are less so than cotton fibres. 
At different parts of the fibre, irregular transverse breaks are seen, which 
are caused by the process of hatchelling. The finest fibrillaB will be found 
broken off in a very irregular manner from the surface of the main fibre, 
being either long or short, and at times branching in different directions. 

Silk Fibres (see Fig. 90). — Silk fibres are homogeneous, moderately 
shining; their cut ends are flattened by the blades of the scissors and 
rendered slightly jagged. If from woven goods, the fibres assume wavy 
or spiral impressions. 

Wool Fibres (see Fig. 91). — Wool fibres are coarse, and have saw- 
teeth-like serrations along the edges, corresponding to the edge of the 
imbricated scales covering the cuticle; their structure is faintly striated. 
Hairs of different animals have different forms., and we may observe the 
central medullary canal and a varying amount of pigment. 

Any of these fibres may be found dyed in different colors, which is 
sometimes quite misleading. 

Human Hairs. — Human hairs are also not infrequently found in the 
urine, and may be known by the flat epidermal scales, firmly attached to 



EXTRANEOUS MATTERS. 195 

each other, which form the main mass of the hair, and by the varying 
amount of pigment. 

Feather (see Fig. 92). — Feather may appear in the shape of branch- 




Fig. 90.— Silk Fibres (X 500). 




Fig. 91.— Wool Fibres (X 500). 

ing formations, which have their origin at the quill, and run in different 
directions or in single barbules. The quill is striated. The barbules are 



196 



URINARY ANALYSIS AND DIAGNOSIS. 



composed of different sized links, and gradually taper toward the ends, 
which are whip-like. 




Fig. 92.— Feather (X 400). 

Scales from Moth (see Fig. 93). — Scales from the wings of insects, 
such as moths, may also be found. They are more or less delicate, ser- 
rated plates with a stem-like projection, and vary considerably in length 
and breadth. 




Fig. 93. — Scales from Wings of Moth (X 500). 



EXTRANEOUS MATTERS. 



197 



Starch Globules (see Fig. 94). — Starch globules are frequently seen in 
the urine. They are more commonly found in the urine of females, starch 
powders being extensively used for dusting purposes, but individual glob- 
ules from the underwear are also seen. They are oval or round, highly 
refractive, and vary greatly in size, with a more or less central hilum or 
umbilicus, around w r hich are concentric striations. The hilum may be 
either round, oval, or irregular, at times quite large, at times small, and 
occasionally appearing as if split. 

The different varieties of starch, although having the same character- 
istics, vary in shape as well as in size. The three most frequently found 




Fig. 94. — Starch Globules (X 500). 
R, Rice starch; C, corn starch; W, wheat starch. 



in the urine are rice starch, corn starch, and wheat starch. Rice starch 
alw T ays appears in the form of oval or oblong, quite regular globules of 
medium size. Corn starch is smaller, irregular, at times almost hexag- 
onal, and contains an irregular hilum. Wheat starch consists of 
large globules, as well as of small, irregular formations, in which latter 
the hilum may be entirely absent or is present only in the form of a 
dot. 

Lycopodium (see Fig. 95). — Lycopodium, somewhat similar to starch, 
and also considerably used for dusting purposes, consists of globular 
formations of different sizes, with a distinct shell, and studded with pe- 



198 



URINARY ANALYSIS AND DIAGNOSIS. 



culiar thorny projections. Many globules seen in urine are partially 
broken, and in some an irregular or triangular division is noticeable. 




Fig. 95. — Lycopodium Globules (X 500). 



Cellulose (see Fig. 96). — Cellulose occurs in the urine in a variety of 
forms, sometimes in small, sometimes in large masses. It varies consid- 
erably, according to the plant or portion of plant from which it is de- 




Fig. 96.— Cellulose (X 500). 



EXT RAN EO US MA TTERS. 



199 



rived, and may be brown, pale yellow, or practically colorless. It may 
be seen in the urine in the form of a framework, sometimes angular, the 
individual cells being connected with each other by the intercellular sub- 




Fig. 97. — Cork (X 500). 

stance. In the interior of many, though not in all, cells, a nucleus, usu- 
ally somewhat irregular, is present, and both the cells and the nucleus 
are granular. 




Fig. 98. — Oil-Globules and Air-Bubbles (X 500). 
F, Fat- or oil-globules; A, air-bubbles. 



200 



URINARY ANALYSIS AND DIAGNOSIS. 



Instead of the irregular angular cells, perfectly regular, either rectan- 
gular or square cells, with large, regular, oblong nuclei, may be seen, and 
these may also be found singly or in masses. 

Cork (see Fig. 97). — A common variety of cellulose seen in urine is 
cork. This occurs either in single cells or smaller conglomerations, and 
has a yellowish-brown or reddish-brown color. The individual cells are 
irregular and greatly vary in size. They are either perfectly homogene- 
ous or contain a small number of indistinct granules. At times many of 
these cells will be found closely packed together. When the cells are thin, 
they may possibly be mistaken for epidermal scales, but their color is 
always sufficient to differentiate them from the latter. 

Oil-Globules and Air-Bubbles (see Fig. 98). — Extraneous fat- or oil- 




Fig. 99. — Flaws in the Glass (X 500). 

globules are of common occurrence in urine. They may be very large 
or extremely small, and are either perfectly round or irregular. They 
are of a high refraction, and can frequently be differentiated by their 
yellowish color. The smallest globules might perhaps be mistaken for 
fat-globules voided with the urine, but are almost invariably associated 
with the larger, more irregular, yellowish globules. 

Air bubbles also vary in size to a great degree, and may be either 
round or irregular; they have a sharply defined, double contour and a 
blue or bluish-black refraction. 

Flaivs in Glass (see Fig. 99). — Flaws in the glass, as well as scratches 



EX TRANEOUS MATTERS. 



201 



in the cover glass, may easily lead to a mistaken diagnosis. The flaws 
are irregular in size and shape, and frequently resemble the wings of a 
butterfly. They have a faint blue refraction and are usually pale. A lit- 




Fig. 100. — Vegetable Matter (X 500). 
Sp, Spiral fibres from air-vessels of plants; V, vegetable fibres; H, hairs of plants ; 
C, cellulose; St, starch-globule; Ch, chlorophyl-globule ; F, fat-globules; M, margaric- 
acid needles ; So, spores. 



tie care is sufficient to diagnose them; and if their identity is not plain, a 
change of the glass will suffice to note their character. 

Rust particles in both the cover glasses and slides also occur, and 
are larger or smaller, dark or rust-brown, irregular masses, which 
must not be mistaken for coloring matter in the urine. The smaller 



202 



URINARY ANALYSIS AND DIAGNOSIS. 



masses somewhat resemble haematoidin crystals, but are always more 
irregular. 

Vegetable Matter (see Fig. 100). — Vegetable matter of different forms 
may be found in the urine as an admixture from the faeces. Different 




Fig. 101. — Normal Reces (X 500). 
MF, Muscle fibres; CT, connective-tissue shreds; Sp, spiral fibre; C, cellulose; H, 
hair of plant; MS, mucus-thread; MC, mucus-corpuscle; E, epithelia; Ph. triple phos- 
phates; St, starch-globules; D, debris; M, mycelium; S, sarcina; Sa, saccharomyces; 
F, fat-globules containing margaric-acid needles; BC , bacilli and cocci. 

plants, which remain partially undigested and may be passed with the 
faeces in small masses, will present a variety of features. Spiral fibres 
from the air-vessels of plants are quite numerous in such masses. Hairs 
of plants, as well as vegetable fibres, the latter resembling connective- 



EXTRANEOUS MATTERS. 203 

tissue shreds, will be found, besides particles of cellulose. We may fur- 
thermore see starch- and chlorophyl-globules, masses of spores, fat-glob- 
ules, and margaric-acid needles. 

Fceces (see Fig. 101). — Normal faeces may occasionally be found mixed 
with urine, and their constituents must be known. If they are present 
and their accidental admixture can be excluded, the diagnosis of a fistula 
can be made. Although their features vary greatly, depending upon the 
food, the most common with a mixed diet are the following: 

Partly digested muscle fibres of a yellowish or brown color are almost 
constantly seen; in many the striations will be plainly visible, while in 
others no structure can be made out. Connective- tissue shreds from the 
meat diet, in small numbers, are also present. Spiral fibres, hairs of 
plants, and different forms of cellulose are almost constant ingredients, 
as well as starch- and chlorophyl-globules, and fat in the form of globules 
and needles. 

Mucus-threads and mucus-corpuscles are usually found in normal 
faeces, as well as different varieties of epithelia. The latter are mostly of 
the flat variety, derived from the mucous membrane of the anus, although 
a few columnar epithelia are not rare. Crystals of various kinds, but 
most commonly triple phosphates, may be quite abundant. Different 
non-pathogenic bacteria, such as conidia and mycelia in small numbers 
(undoubtedly secondary products), saccharomyces, and large numbers of 
bacilli and cocci, may be found. Besides these features masses of debris, 
digested material, in smaller or larger conglomerations, will be seen. 

The extraneous matters here enumerated as occurring in the urine are 
those which are more commonly found, but other features may be seen at 
one time or another. For instance, water fungi of different varieties, al- 
though rare, are known to occur in urine. It will, however, be a com- 
paratively easy matter to recognize most of the extraneous objects. 



PART THIRD. 

MICROSCOPICAL URINARY DIAGNOSIS. 



PART THIRD. 

MICROSCOPICAL URINARY DIAGNOSIS. 



Although it has been customary, in arriving at a correct diagnosis of 
diseases of the genito-urinary tract, to consider the microscopical exam- 
ination of the urine as only of secondary importance, and, in diagnosing 
the different inflammations of the kidney, to rely solely upon the pres- 
ence of casts, a perusal of the previous pages will show that the micro- 
scope is not only of the utmost importance in all these affections, but is 
frequently the only means of arriving at correct conclusions as to the nat- 
ure of the case. 

It is a well-known fact that in many cases in which a small amount of 
albumin is present in the urine, and in which the clinical symptoms seem 
to point to a nephritis, even if only slight, that diagnosis will not be made, 
because frequent examinations of the urine fail to reveal any tubular 
casts, and the physician is apt to rest satisfied with the diagnosis of 
'•functional albuminuria"; yet a large number of not infrequently se- 
vere cases of nephritis exist which never show casts in the urine. In cir- 
rhosis of the kidney, for instance, the presence of true casts is quite rare, 
and, when they are present at all, may be so scanty as to be entirely over- 
looked. 

On the other hand, many cases of nephritis, often lasting for years, 
will give such ill-defined clinical symptoms that a kidney inflammation 
is rarely thought of; and the examination of the urine, if made at all, is 
done rapidly and merely with the idea of satisfying one's self that casts 
are not present. Many of these cases will show only a trace of albumin in 
the commencement stage, and might not only be greatly benefited, but 
entirely cured, if a proper diagnosis were made soon enough. Such a 
diagnosis can always be made from a microscopical examination of the 
urine, even without the presence of casts, and the larger number of the 
mild cases never show true casts in the urine at any time. 

The diagnosis of an inflammation or other affection of the kidneys is 

undoubtedly the most important, but a microscopical examination of the 

urine may also be the only means of positively diagnosing the nature of a 

disease of the pelvis of the kidney, the bladder, and the prostate gland, as 

207 



208 URINARY ANALYSIS AND DIAGNOSIS. 

well as of clearing up a suspected case of inflammation of the seminal ves- 
icles. In the female, an inflammation or ulceration of the vagina, the 
cervix uteri, and the mucosa of the uterus can often be positively identi- 
fied from the examination of urine, without the necessity of an examina- 
tion of the patient. It can thus easily be seen that the microscope plays 
an extremely important role in geni to-urinary affections, either giving the 
first evidence of a disease or helping to clear up a doubtful diagnosis. 

In the following pages only those affections will be considered which 
can be positively diagnosed from a microscopical examination of the urine. 



CHAPTER XVI. 

DISEASES OF THE KIDNEY AND PELVIS OF KIDNEY. 
I. INFLAMMATIONS OF THE KIDNEY AND ITS PELVIS. 

Classification. — There are probably no diseases in which the opin- 
ions of pathologists differ so much, and in which the nomenclature is so 
varied, as in inflammations of the kidney — nephritis. The result must 
necessarily be confusion. Such different terms as Bright's disease, inter- 
stitial, desquamative, exudative, parenchymatous, and diffuse nephritis 
are met with, and congestion or hyperemia, glomerulitis, pyelo-nephritis, 
and amyloid disease are all looked upon as different affections. While 
some authors use the term Bright's disease as indicating all the different 
varieties of nephritis, others call diffuse nephritis Morbus Brightii; others, 
parenchymatous nephritis; and still others, combinations of different va- 
rieties. 

A uniform classification of nephritis is difficult, since various phases 
of inflammation and degeneration are closely associated and often merge, 
and some authors separate a number of these different phases. One 
classification* is the following: 1. Acute parenchymatous nephritis or 
acute Bright's disease. Varieties of this form are acute degenerative ne- 
phritis, acute catarrhal or desquamative nephritis, acute glomerulo- 
nephritis, acute diffuse nephritis, to which belongs the hemorrhagic form. 
2. Acute interstitial nephritis, non-suppurative in character, and suppu- 
rative nephritis. 3. Chronic parenchymatous nephritis ; to this form be- 
long chronic diffuse and chronic hemorrhagic nephritis, also the large 
white kidney. Its terminal form is known as fatty contracting kidney or 
secondary interstitial nephritis. 4. Chronic interstitial nephritis, divided 
into primary chronic interstitial or red granular kidney or arteriosclerotic 
nephritis or gouty nephritis, and secondary chronic interstitial, the ter- 
minal form of chronic parenchymatous nephritis. 

Delafield and Pruddenf mention three principal varieties of inflam- 
matory processes of the kidney: 1. Acute suppurative nephritis. 2. 
Acute diffuse nephritis. 3. Chronic diffuse nephritis. The variations in 

* Stengel and Fox, "Textbook of Pathology," 6th Edition, 1915. 
f "Text-Book of Pathology," 11th Edition, 1919. 
14 209 



210 URINARY ANALYSIS AND DIAGNOSIS. 

type in acute diffuse nephritis are the following : (a) Glomerulo-nephritis ; 
(b) parenchymatous or degenerative type; (c) hemorrhagic type; (d) ex- 
udative type; (e) productive type or interstitial type. Variations in type 
in chronic diffuse nephritis are: (a) Parenchymatous or degenerative 
type; and (6) interstitial type. 

Adami and McCrae* divide nephritis into acute interstitial, acute 
parenchymatous, chronic interstitial and chronic parenchymatous. 
Of these, all but the first are called Bright's disease; in the first, exu- 
dative changes are the most prominent, in the last three, degenerative. 
Suppurative nephritis is an advanced form of acute interstitial. 

It is unnecessary to go any further into the different classifications, 
which no two authors give alike, but it may be mentioned that some pre- 
fer to speak primarily of an acute and a chronic nephritis only, dividing 
them into parenchymatous and interstitial secondarily. 

It is, therefore, not at all surprising that the pathology of nephritis is 
considered to be one of the most complicated chapters in pathology ; yet 
it will become perfectly plain, and the features found in urine easily ex- 
plained, if we consider the anatomical structure of the kidney, which is 
that of a compound tubular gland, consisting of epithelial and connective 
tissue; the latter alone carries the blood-vessels, the contents of which, 
the blood, furnish the material from which the epithelia produce the 
secretions. 

Experiments have frequently been made to show that pathological 
conditions of the epithelia can exist independently of the underlying con- 
nective tissue carrying the blood-vessels. It has been asserted that in 
acute cases of poisoning, such as with cantharides and phosphorus, the 
pathological process is confined to the kidney epithelia alone. Other ex- 
periments have, however, conclusively proved that an independent path- 
ological condition of the epithelia does not exist. The poison, before it 
reaches the epithelia, must pass the walls of the blood-vessels and the 
connective tissue lying between the epithelia and the walls of the blood- 
vessels, and has an irritating influence upon the latter. In this connec- 
tive tissue, changes are always found, though they may be confined to 
serous transudation, sufficient to show that the epithelium cannot be- 
come diseased primarily and independently of the surrounding connective 
tissue. 

It is, therefore, evident that the classification by Virchow, of inflam- 
mations into interstitial, that is, confined to the connective tissue, and 
parenchymatous, confined to the epithelia, is not strictly correct. Every" 
inflammation is primarily an interstitial one, and every parenchymatous 

* "Text-book of Pathology," 2nd Edition, 1914. 



DISEASES OF THE KIDNEY AND PELVIS. 211 

inflammation must also at the same time be an interstitial one. It is per- 
fectly true, however, that the pathological changes may be more pro- 
nounced in the epithelia than in the connective tissue; the latter may 
not pass beyond the stage of serous infiltration, while in the former 
coarse granulation, so-called cloudy swelling, may occur. In cases of 
phosphorus poisoning fatty degeneration may be present. 

The character of an inflammation depends to a great degree upon the 
nature of its exudate, which may be either serous, fibrinous, or albumin- 
ous. In former years inflammations of mucous membranes were divided 
into catarrhal and croupous; in the first a serous or sero-mucous exudate 
is formed, while in the second it is fibrinous in its character. These 
names, though not of great significance, are perhaps preferable to Vir- 
chow's terms — interstitial, desquamative, and parenchymatous — which, 
as has been shown, cannot be carried out. An inflammation in an organ 
composed of connective and epithelial tissue will affect all its component 
parts to a greater or less degree, so that it will be diffuse to a certain ex- 
tent at the outset. The difference exists only in the degree in which the 
different tissues are affected. We may, if we wish, speak of an interstitial 
inflammation when the pathological changes are more pronounced in the 
connective tissue, and of a parenchymatous inflammation when they are 
more pronounced in the epithelia. 

As every inflammation of the kidney is bound to be more or less dif- 
fuse in its character — by which term is not meant that it affects the en- 
tire organ uniformly, but simply all the component parts of the organ at 
the seat of inflammation — and the term Bright's disease conveys no 
meaning as to the character of the inflammation, which may run an 
acute, subacute, or chronic course, all cases of nephritis may best be 
divided in the following manner: 

1. Interstitial, catarrhal, or desquamative nephritis. 

(a) Acute. 

(b) Subacute. 

(c) Chronic, terminating in cirrhosis of the kidney. 

2. Parenchymatous or croupous nephritis. 

(a) Acute. 

(b) Subacute. 

(c) Chronic, terminating in atrophy of the kidney. 

3. Suppurative nephritis. 

(a) Acute. 

(6) Chronic. 
When the greater part or the entire kidney is transformed into a puru- 
lent cavity, the term pyonephrosis is applied. 

Congestion or hyperemia of the kidney cannot be considered as a sep- 



212 URINARY ANALYSIS AND DIAGNOSIS. 

arate affection, since it is either the first stage of a commencing inflam- 
mation or a mere irritation, which cannot be properly termed inflamma- 
tory as yet, but which sooner or later will undoubtedly develop into an 
inflammation. 

Glomerulitis or glomerulo-nephritis is not an independent inflamma- 
tory process, but only a symptom of one of the inflammations, since the 
glomeruli are always attacked to a greater or less degree in every nephritis. 

Fatty and waxy, or amyloid, degenerations of the kidney are almost 
invariably secondary products, due to a chronic inflammation, and part 
of such an inflammation. 

Pathological Changes. — Let us now briefly consider the pathological 
changes which take place in these different inflammations of the 
kidney: 

1. Interstitial Inflammation. — In interstitial or catarrhal inflamma- 
tion of a mild character, an cedematous swelling of the connective tissue 
is present, with swelling and granular cloudiness of the epithelial cover- 
ing and subsequent desquamation of the epithelium. The blood-ves- 
sels show a more or less complete distention with blood-corpuscles, with- 
out apparent alteration in the structure of their walls. The cedematous 
swelling of the connective tissue, as well as the desquamation of the epi- 
thelia, is due to a serous exudation from the blood-vessels. On account 
of this serous exudation, the epithelia may undergo degenerations. 

In severer cases an inflammatory infiltration of the connective tissue, 
which leads to hypertrophy, takes place, with proliferation, desquama- 
tion, and, finally, hyperplasia of the epithelium. In the highest degree of 
catarrhal inflammation, all the constituent parts of the kidney tissue have 
disappeared in the inflammatory infiltration. 

At the very commencement of an inflammation, the production of 
pus-corpuscles takes place, partly from the emigration of white blood- 
corpuscles, partly from the interstitial connective tissue and partly from 
the epithelium, which latter undoubtedly enters into the formation of 
pus-corpuscles to a great degree by division and endogenous cell-prolif- 
eration, as had already been shown by George Johnson, in the year 
1852. As long as the newly formed corpuscles remain in connection with 
the tissue, we have inflammatory corpuscles; but as soon as they are 
torn from their connection with the tissue and appear in the urine, the 
term pus-corpuscles must properly be applied to them. 

When the disease has become chronic, the surface of the kidney is 
marked by irregular, shallow depressions, or by granulations, the capsule 
being adherent in most cases. The irregular depressions are due to re- 
tractions of newly formed connective tissue, which is formed at the ex- 
pense of the uriniferous tubules. Chronic catarrhal or interstitial nephri- 



DISEASES OF THE KIDNEY AND PELVIS. 213 

tis invariably leads to a shrinkage — cirrhosis — of the kidney. The whole 
kidney is considerably reduced in size, and the irregularities on the surface 
are well marked. Both the cortical and medullary substances are much 
narrower than in the normal condition ; this being more particularly the 
case in the cortex, of which, in advanced stages, only slight remnants are 
left, corresponding with the elevations of the surface. There is a partial 
destruction of tufts or glomeruli, tubules, and blood-vessels. The newly 
formed connective tissue is more or less regularly distributed throughout 
the kidney structure, the uriniferous tubules being in part transformed 
into connective tissue, while still retaining the outlines of their original 
configuration. 

The obliteration of a number of the narrow tubules, including the 
ascending and descending branches, explains the clinical fact that per- 
sons affected with cirrhosis of the kidney void large quantities of urine 
almost destitute of salts. It is well known that from the glomerulus only 
a watery liquid, containing few salts, is voided, which becomes thicker by 
the addition of the saline constituents excreted by the narrow tubules. 
It is in the narrow tubules that much of the watery part of the urine is 
restored to the thickened blood running in the neighboring capillaries. 
If the function of the tubules be much interfered with, the interchange 
between the liquid contents of the tubule and the solid constituents of the 
blood will not take place, and consequently the urine will be voided in 
about the same condition in which it was pressed into the capsule from 
the tuft. Numbers of the convoluted tubules perish also through the in- 
creased formation of connective tissue, while from others the epithelia are 
simply desquamated and appear in the urine. 

2. Parenchymatous Inflammation. — In parenchymatous or croupous 
inflammations the surface becomes partially or completely denuded of 
its epithelium, a coagulated albuminous or fibrinous exudate is formed 
upon the surface, there is considerable hyperemia of the blood-vessels, 
as well as a pronounced swelling and inflammatory infiltration of the 
connective tissue. Undoubtedly the epithelia enter very actively in 
the formation of the so-called croup membrane, and their protoplasm 
becomes almost completely destroyed in the fibrinous exudate. 

In this variety of inflammation the emigration of colorless blood-cor- 
puscles is quite pronounced. Epithelia alone cannot produce a croup 
membrane, but require the presence of an exudate from the blood, and 
the essential constituent of the croup membrane is the coagulable albu- 
minoid body from the blood. We now have the formation of casts ; the 
epithelia lining the tubules become saturated with the albuminous exu- 
date, swell, grow pale, and finally, by coalescence of the epithelia thus 
degenerated, produce the mass called a tubular cast. 



214 URINARY ANALYSIS AND DIAGNOSIS. 

In chronic parenchymatous nephritis the kidney has an entirely 
different appearance from that found in chronic interstitial nephritis 
and cirrhosis of the kidney. It is more frequently enlarged than di- 
minished in size. The surface is often nodulated, and between the no- 
dules are seen deep cicatricial retractions. These retractions are never 
found uniformly over the surface, and the capsule is adherent to the re- 
tractions. The cortical substance is absent in those parts correspond- 
ing with the retractions of the surface, while in other places the cortex 
may be unaltered or even increased in bulk. The pyramidal substance 
may be unchanged or may be diminished. In contradistinction to the 
more or less uniform shrinkage of the kidney, to which the name 
cirrhotic is given, the partial destruction of the tissue which occurs in 
chronic parenchymatous nephritis may be termed atrophy, since in the 
most diseased portions only traces of the original kidney structure are left. 

In the depressed cicatricial portions of the cortical substance a large 
amount of connective tissue, only scantily supplied with blood-vessels, is 
found. There is no regularity in the arrangement of the connective tis- 
sue, and only remnants of the former tubules are found, together with ir- 
regularly scattered sections of tubules, from which the epithelial lining 
has entirely disappeared. In the most pronounced cases, in addition to 
the atrophied portions, the large amount of newly formed connective tis- 
sue present in different places constitutes a regular hypertrophy. 

Both fatty and waxy degeneration may be present in cirrhotic as well 
as in atrophied kidneys, but these changes are much more pronounced in 
the latter than in the former. In the so-called large white kidney, the 
highest degree of fatty degeneration occurs as a secondary result of 
chronic parenchymatous nephritis. Cystic degeneration may also be 
present in these cases, and is more pronounced in chronic paren- 
chymatous nephritis. 

3. Suppurative Inflammation. — The most intense variety of inflamma- 
tion of the kidney is the suppurative, which is similar to the formation of 
suppuration in other organs. It is a distinctly different process from the 
purely interstitial type although some authors consider it an advanced 
form of interstitial. In it there is an excessive emigration of polymorpho- 
nuclear leucocytes together with a liquefaction of the different tissues. 
Many blood-vessels soon become destroyed. In the formation of pus a 
disintegration of tissue occurs, and all the elements of the tissue take part. 

There may be either a number of small disseminated foci of suppura- 
tion or a large abscess, usually, if not invariably, caused by an invasion 
of pyogenic cocci. Besides the abscess, the kidney may present the feat- 
ures either of an interstitial or of a parenchymatous inflammation. 
When the abscesses become chronic, a dense connective-tissue capsule, 



DISEASES OF THE KIDNEY AND PELVIS. 215 

the pyogenous membrane, may occasionally be found, and the pus be- 
comes inspissated into a cheesy mass. 

With these remarks upon the pathology of the different varieties of 
nephritis, we are ready to understand the features found in the urine of 
these cases. Although it is not possible to diagnose an acute, subacute, 
or chronic inflammation from the urine alone, in all cases of nephritis, it 
can undoubtedly be done from the different features seen in most cases, 
especially the more pronounced. 



CONGESTION OR HYPEREMIA OF THE KIDNEY. 

From what has been said before, it is evident that the diagnosis of an 
inflammation can be made as soon as pus-corpuscles are found in the 
urine; without these, no such diagnosis is possible. In some cases, in 
which a trace or faint trace of albumin is present, an extremely small 
number of pus-corpuscles or rather leucocytes, perhaps one or two in 
every field of the microscope, is seen, together with the same number of 
epithelia from the uriniferous tubules, and a few red blood-corpuscles. 
These features, when present in such very small numbers, are not 
sufficient for the diagnosis of an inflammation, though the urine can- 
not be called normal. In such cases the diagnosis of a congestion or 
hypercemia of the kidney is possible, and in them we do not, as a rule, 
find true casts. In severe cases a few hyaline casts may be found, and 
red blood-corpuscles are somewhat more numerous. In such cases a 
differentiation between congestion and inflammation may be difficult. 

In some cases of congestion mucus-threads and cylindroids, which 
latter can sometimes hardly be distinguished from hyaline casts, may 
be present, this being especially the case in acute eruptive and inflam- 
matory diseases, such as scarlatina, diphtheria and pneumonia. The 
color, amount of urine and specific gravity may be normal in mild cases; 
in severe cases the urine is highly colored, the quantity diminished and 
the specific gravity high. In chronic cases fat globules are present. 

Causes. — Congestion of the kidney is of common occurrence, but is 
frequently overlooked. It may be present accompanying almost any dis- 
ease, and may be produced by different medicinal agents, such as cu- 
bebs, copaiba, turpentine, cantharides, and mineral acids. Occasionally it 
seems as if simple exposure to cold and moisture is sufficient to produce 
it. In cases of catarrhal or gonorrheal urethritis, especially if accom- 
panied by slight prostatitis, an irritation of the kidney is often found, 
giving the features enumerated above. The presence of an increased 



216 URINARY ANALYSIS AND DIAGNOSIS. 

amount of salts, such as uric acid or calcium oxalate, will not infrequently 
be responsible for the condition. 

If the cause which has produced the congestion be quickly removed, 
the affection may disappear at once; but if not, an inflammation will 
sooner or later result. 

If the congestion is pronounced, a more or less severe hemorrhage from 
the kidney may take place, even without an inflammation. In such cases 
red blood-corpuscles will be numerous, epithelia from the convoluted tu- 
bules may be somewhat more abundant, and, in addition, scanty, delicate 
shreds of connective tissue will appear in the urine. All the features may 
have a yellowish hue from the coloring matter of the blood. 



INTERSTITIAL OR CATARRHAL NEPHRITIS. 

Interstitial, catarrhal, or desquamative nephritis frequently runs a 
comparatively mild course, being, as a rule, the mildest of the three vari- 
eties of inflammation. Severe acute cases, which may cause the death 
of the patient 2 do, however, occur. Interstitial nephritis is a much more 
common affection than is generally supposed, and may exist for many 
years without giving any pronounced clinical symptoms. It is by no 
means rare that a urine which is examined microscopically with a view of 
detecting other affections will show the presence of such an inflammation 
before the clinical symptoms are clear, though the patient may have suf- 
fered for a long time from occasional headaches and general depression. 

Causes. — Interstitial nephritis often exists in a mild degree without 
any known cause. Exposure to cold and moisture seems to be a fre- 
quent cause, as are also different medicinal agents, such as arsenic, io- 
dine, phosphorus, mercury, turpentine, and cantharides. In lead-poi- 
soning the disease is often present. It is not infrequently found in 
persons of sedative habits and in those with a so-called gouty or rheu- 
matic diathesis. That persons suffering from gout and rheumatism 
usually void a large amount of uric acid is well known ; but there are others 
who continually void uric acid and calcium oxalate in excess without giv- 
ing any rheumatic symptoms. In these cases — lithsemia and oxaluria — 
interstitial nephritis frequently occurs, and it seems that the excess of 
the salts, or the concentration of the urine itself, has an irritating tend- 
ency upon the kidney tissue. The continued use of alcohol is an im- 
portant factor in the production of the disease. 

In acute contagious diseases parenchymatous nephritis is of more 
common occurrence than interstitial, but the latter, contrary to the 
general belief, undoubtedly occurs. If the urine is carefully examined 



DISEASES OF THE KIDNEY AXD PELVIS. 217 

in these diseases, a small amount of albumin, perhaps not more than a 
trace, may be found in the milder cases, and upon microscopical examina- 
tion the features of an interstitial infla mmation are seen. Even in some 
fatal cases, an examination of the kidney may reveal an interstitial and 
not a parenchymatous inflammation. In pregnancy, also, interstitial 
nephritis occurs, and is not at all rare. 

As a secondary affection, this variety of inflammation may be present 
in many acute and chronic fatal diseases, so much so that, upon post- 
mortem examinations, absolutely healthy kidneys are usually found only 
after death by accident, 

Finally, interstitial nephritis is common as a result of various genito- 
urinary affections, as, for instance, in some cases of gonorrhoea, when first 
a prostatitis, then, in succession, a cystitis, pyelitis, and nephritis will de- 
velop. In syphilitic and tubercular affections it is frequently seen. 

Clinical Symptoms. — The clinical symptoms of the disease vary greatly, 
but in the milder cases are anaemia, occipital headache, pain in the lumbar 
region, loss of appetite, sleeplessness, and general depression. In cirrhosis 
of the kidney the symptoms are pronounced, loss of flesh and strength is 
well marked, vomiting may be frequent, there may be dyspnoea, and the 
pulse is tense, hard, and often full. The acute cases may occur at any age, 
but the chronic cases are mostly found in persons more advanced in years, 
especially after the age of forty years. 

Features Found in Urine. — Albumin, although present in most of the 
cases, may be found in very small amount only, and in some it seems to 
be entirely absent. A large amount of albumin is rare in interstitial ne- 
phritis, and is seen only in the severe cases. In many, a trace of albumin 
only will be found, and unless a careful observation is made, it may escape 
detection entirely. The question whether a pronounced inflammation of 
the kidney may exist with entire absence of albumin is still an open one. 
Many authors claim that it does occur, but many times when albumin is 
said to be absent careful examination will show a trace. It is undoubt- 
edly a fact that in interstitial nephritis albumin may be absent at 
certain times, but frequent examination will almost invariably show at 
least a trace in every case. 

The specific gravity, amount, and appearance of the urine will vary 
greatly. In milder cases these may be perfectly normal. In acute in- 
terstitial nephritis the specific gravity is, as a rule, somewhat higher than 
normal, the amount slightly decreased, and the color darker. The amount 
of urea is usually increased, and salts may be present in rather large num- 
bers. In chronic cases the amount of urine is invariably increased, some- 
times to a great degree; the specific gravity is low and the color pale. 
In such cases the specific gravity is not infrequently below 1.012 or 1.010 



218 URINARY ANALYSIS AND DIAGNOSIS. 

continually, the amount of urea and salts being diminished. The sedi- 
ment found in the urine varies, but is usually small, and may at times 
be no more abundant than in normal urine. 

A positive diagnosis of interstitial or catarrhal nephritis is in many 
eases possible only by a microscopical examination of the urinary sedi- 
ment. This will vary in acute, subacute, and chronic cases. The diagno- 
sis of a nephritis can be made when pus-corpuscles and epithelia from the 
convoluted and narrow tubules of the kidney are present in the urine. 
Columnar epithelia from the straight collecting tubules are of rarer oc- 
currence, and indicate an invasion of the pyramidal substance. 

Before the presence of epithelia from the convoluted tubules of the 
kidney can be diagnosed, pus-corpuscles must be found and taken as a 
standard, since the latter vary in size to a certain degree in every given 
case. Kidney epithelia from the convoluted tubules are about one-third 
larger than the pus-corpuscles. These epithelia are never found in nor- 
mal urine, and to render their diagnosis positive, they should always be 
compared with pus- or white blood-corpuscles. A single kidney epithe- 
lium is of no value for the diagnosis, and a small number, at least, should 
always be found, in order to render the diagnosis positive, since, as is well 
known, pus-corpuscles vary in size to a small degree even in the same case. 
This difference is, however, small, and never so pronounced as to render 
the diagnosis between pus-corpuscles and kidney epithelia difficult. The 
difference in size between the two can alone determine the nature of the 
epithelia, since the presence or absence of a nucleus has no significance 
whatever. A nucleus maybe seen in pus-corpuscles, as well as in epithe- 
lia, though it is found more frequently in the latter than in the former. 
In finely granular pus-corpuscles a nucleus will always be visible, while 
in coarsely granular epithelia it may not be seen. 

Kidney epithelia from the convoluted as well as those from the narrow 
tubules generally have a round shape in urine, though angular or irregu- 
lar forms are also seen. When the urine is still warm at the time of ex- 
amination, or in a warm temperature, the pus corpuscles may not infre- 
quently show amoeboid movement and assume a variety of different 
shapes, while the kidney epithelia, as a rule, retain their round or slightly 
irregular form.* 

In this variety of nephritis casts are usually absent; if they are pres- 
ent at all, they are found in extremely small numbers, and then we almost 

* Attention should here again be called to the fact that low magnifying powers 
of 100 or 150 diameters are absolutely useless for a diagnosis of kidney epithelia. 
A magnifying power of at least 400 diameters must be used, and with such a 
power the difference between pus-corpuscles and kidney epithelia becomes appar- 
ent at once. 



RB- 




'TJG 



Fig. 102. — Acute Interstitial Nephritis (Acute Catarrhal Pyelo-Xephritis) 

and Cystitis (X 500). 

RB, Red blood-corpuscles ; PC, pus-corpuscles : CE, epithelia from the convoluted tubules 
of the kidney; UE, epithelia from the ureter; PE, epithelia from the pelvis of the kidney; 
UB, epithelia from the upper layers of the bladder; MB, epithelium from the middle 
layers of the bladder; UA, uric acid; UG, uric-acid gravel; US, sodium urate; OC. 
Galcium oxalate. 



DISEASES OF THE KIDNEY AND PELVIS. 221 

invariably see small hyaline casts from the narrow tubules only. The 
diagnosis, however, hinges upon the presence of epithelia from the con- 
voluted and narrow tubules and pus corpuscles, together with other feat- 
ures to be presently mentioned. 

Acute Interstitial or Catarrhal Nephritis (Fig. 102). — In an acute 
interstitial nephritis the pus-corpuscles and cuboidal epithelia from the 
convoluted tubules of the kidney are present in at least moderate but 
usually large numbers; the more numerous these features, the severer is 
the nephritis. Besides these, we usually find red blood-corpuscles in mod- 
erate or fairly large numbers, though they are not sufficiently numerous 
to admit of the diagnosis of a hemorrhage. Moderate numbers of red 
blood-corpuscles always indicate an acute inflammation. 

These three features are perfectly sufficient for the diagnosis, but are 
rarely found alone. In many cases different salts, such as calcium oxa- 
late, uric acid, and sodium urate, are found in small amount. In the se- 
verer cases a few columnar epithelia from the straight collecting tubules 
are also present. As a general rule, an inflammation of the pelvis of the 
kidnejr is associated with the nephritis, though this may be absent. 
When present, the irregular, lenticular, pear-shaped, or angular epithelia 
from the pelvis are also seen in varying numbers, and the diagnosis of a 
pyelo-nephritis can be made. Such a diagnosis does not by any means 
suggest an abscess of the kidney, as is frequently supposed, but simply 
the extension of the inflammatory process to the pelvis of the kidney. 
Besides these, epithelia from the ureters in small numbers, which are 
about twice the diameter of pus-corpuscles, and therefore larger than the 
kidney epithelia, are rarely absent. 

If the nephritis is at all pronounced, symptoms of an accompanying 
cystitis are also seen, and we will then find larger cuboidal epithelia from 
the middle layers of the bladder — which in urine appear round or oval in 
most cases — as well as flat epithelia from the upper layers with the other 
features. 

The severer the acute inflammation the more abundant are the ac- 
companying features of pyelitis and cystitis. In such severe cases hya- 
line casts from the narrow tubules are occasionally present; if these are 
seen in small numbers only, the diagnosis does not necessarily become 
changed. The latter feature is comparatively rare, and in most cases 
casts of any kind are entirely absent. 

Chronic Interstitial or Catarrhal Nephritis (Fig. 103). — As soon as 
the inflammation has become chronic, the features in the urine are differ- 
ent. Red blood-corpuscles are now either entirely absent, or, when pres- 
ent, are found in small numbers only. We observe, however, a varying 
number of small, gHstening, highly refractive globules and granules, partly 



222 URINARY ANALYSIS AND DIAGNOSIS. 

lying free, partly in the pus-corpuscles and epithelia. These are fat-glob- 
ules and -granules, and the more numerous they are the more chronic is 
the inflammation. They are found in larger or smaller groups scattered 
throughout the field, and are seen in varying numbers in the pus-corpus- 
cles and epithelia. In milder cases only two or three may be present in 
some epithelia, while they are absent in others; but in the old, chronic 
cases almost every epithelium will be seen filled with the glistening glob- 
ules. When very numerous, they not only denote chronicity, but also a 
commencing fatty degeneration of the kidney, which, in this variety of 
nephritis, is never pronounced. Fat-globules are not seen in acute cases. 

The features found in a chronic interstitial nephritis are, therefore, 
the following: Pus-corpuscles, some containing fat-globules and -gran- 
ules; cuboidal epithelia from the convoluted tubules of the kidney, a 
few, or a large number, containing fat-globules; free fat-globules in dif- 
ferent groups; in the severer cases, also, columnar epithelia from the 
straight collecting tubules, usually in small numbers only. Irregular or 
round epithelia from the pelvis of the kidney, cuboidal (round) epithelia 
from the ureters, and still larger cuboidal epithelia from the middle lay- 
ers of the bladder, either with or without fat-globules, may be present in 
small or moderate numbers. A few granular casts may be seen. 

Another feature of chronicity which may occasionally be found is 
hsematoidin, in the form of rust-brown needles and plates. These may 
either lie free or when of small size may be seen in the pus-corpuscles and 
epithelia. They denote a previously existing hemorrhage, and show that 
the pathological process cannot be an acute one. 

Red blood-corpuscles, as previously mentioned, are either entirely ab- 
sent in a strictly chronic case, or, when present, are found in small num- 
bers only. Not infrequently, however, all the features of a chronic in- 
flammation are seen, and yet blood-corpuscles are fairly numerous. This 
invariably denotes a fresh acute outbreak engrafted upon the chronic 
process. Such acute attacks are not rare in cases of long standing, and 
may be produced by the slightest cause, such as exposure to cold, de- 
rangements of digestion, etc. Again, the chronic inflammation may be 
confined to one kidney and an acute process affect the second kidney. 

In Subacute Interstitial Inflammations some features of both the 
acute and the chronic form will be found. We have a small or moderate 
number of red blood-corpuscles and a small number of fat-globules, 
the latter being rarely seen in groups, but only in a few pus-corpuscles 
and epithelia, and there may be only one, two, or three in them. The 
other features remain the same. 

When the features as here described are present, it will not be difficult 
to tell whether an inflammation is acute, subacute, or chronic : but some 



TS © W 1 

® © © *~^ 

® * 




Fig. 103. — Chronic Interstitial Nephritis (Catarrhal Pyelo-Nephritis) 

and Cystitis (X 500). 
PC, Pus-corpuscles containing fat-globules; CE, epithelia from the convoluted tubules 
of the kidney containing fat-globules ; SE, epithelium from the straight collecting tubules 
of the kidney containing fat-globules; UE, epithelia from the ureter containing fat- 
globules; PE, epithelia from the pelvis of the kidney; MB, epithelia from the middle 
layers of the bladder; FG, free fat-globules; RB, individual red blood-globule. 



DISEASES OF THE KIDNEY AND PELVIS. 225 

cases may at times be seen where neither red blood-corpuscles nor fat- 
globules can be discovered, and then the diagnosis of a simple intersti- 
tial or catarrhal nephritis can alone be made. These cases are usually 
of a mild character. 

The severity of the inflammation as well as its duration can be 
determined more readily by the urinary features than by the clinical 
history, which may be vague. The less marked the features after 
repeated examinations of the twenty-four hours' mixture, the less 
severe the case is liable to be. The more abundant the fat globules 
both in the pus-corpuscles and in the epithelia and the more marked 
free groups of fat globules are, the more chronic is the inflammation. 

Cirrhosis of the Kidney (Fig. 104). — The outcome of chronic inter- 
stitial nephritis is always a shrinkage — cirrhosis — of the kidney, the so- 
called hob-nail kidney. The features of this, as seen in the urine, are so 
characteristic that a positive diagnosis can always be made. They are 
the following: 

1. A large amount of urine, being occasionally increased to double the 
normal quantity or more, and the color being pale. 

2. A continuously low specific gravity, usually below 1.012 or 1.010, 
or even not more than 1.006 or less at any time. 

3. The presence of a small amount or perhaps not more than a trace 
of albumin. 

4. A diminution of all salts. 

5. Pus-corpuscles, present in small numbers, some containing fat- 
globules. 

6. Epithelia from the convoluted and straight collecting tubules of 
the kidney, in small numbers, some or even all containing fat-globules. 

7. Free fat-globules and -granules. 

8. Connective-tissue shreds, of small sizes and in small numbers only. 

9. A few granular and also fatty casts. Such casts need, how- 
ever, not necessarily be present and in many cases of cirrhosis no true 
tube-casts whatever are found. 

Epithelia from the pelvis of the kidney, the ureter, and the middle 
layers of the bladder may also be present. 

As previously explained, urine from a badly diseased kidney contains 
few salts. In some cases, in which all the other features of a cirrhosis are 
present, a large amount of salts, such as uric acid or phosphates, is also 
seen, the specific gravity being 1.014 or higher. The conclusion which 
can then be reached is that only one kidney has so far become affected, 
the salts being voided by the other kidney. The prognosis will, in such 
cases, be better than when salts are not seen under the microscope. 

Catarrhal Pyelitis. — A few words should here be said about ca- 

15 



226 URINARY ANALYSIS AND DIAGNOSIS. 

tarrhal pyelitis, which may occur as a primary or as an ascending af- 
fection. It has been claimed that the term " catarrhal" for an inflam- 
mation of the pelvis of the kidney is incorrect. As these inflammations, 
however, have undoubtedly the character of catarrhal processes,* we 
can speak of catarrhal pyelitis, just as of catarrhal nephritis. 

When pyelitis occurs as such, it is easily diagnosed from the urine, 
the features being the same as in interstitial nephritis, except that 
pelvic epithelia instead of kidney epithelia are found. Being in many 
cases due to an abundance of salts, these will usually be present in such 
cases. Not infrequently, pyelitis is an accompanying element of a 
nephritis, giving us a catarrhal pyelo-nephritis, with the features as 
above described 

Ureteritis. — A primary, independent inflammation of the ureter is 
rare, a ureteritis being almost invariably secondary to a pyelitis or a 
cystitis. It may be caused by infections of any kind or may be due to 
impacted calculi. In a catarrhal inflammation the same features as 
those seen in nephritis and pyelitis are seen, except that epithelia from 
the ureter alone are found. Ulceration and suppuration may also 
occur, giving features similar to those seen in ulcerative and suppura- 
tive conditions to be described in other organs. In the latter processes, 
however, columnar epithelia are present. In injury to the ureter due to 
the ureteral catheter, red blood- corpuscles, small cuboidal and columnar 
epithelia, and connective-tissue shreds are seen in the urine. 

PARENCHYMATOUS OR CROUPOUS NEPHRITIS. 

Parenchymatous nephritis is usually a severer affection than the in- 
terstitial, and is not quite as frequent as the latter. When present, its 
symptoms are always more or less pronounced, and only in rare cases 
will it exist for some time without giving symptoms sufficiently char- 
acteristic to suspect a nephritis. 

Causes. — Its causes are numerous, being partly the same as those 
found in the interstitial variety. Exposure to cold and moisture is a 
common cause, and it is not infrequently the consequence of irritant 
poisons acting upon the system, such as turpentine, bichloride o{ mer- 
cury, cantharides, arsenic, large doses of iodide of potash, and occa- 
sionally even chlorate of potash. As in interstitial nephritis, it may be 
found in persons of a sedative habit and in those suffering from a 
lithaemia. The continued use of alcohol is an important causative 
factor. 

Among the most common causes in the production of the disease are 

* Adami and Nicholls. The Principles of Pathology, Vol. II, 1909. 




Fig. 104. — Cirrhosis of the Kidney, with Chronic Catarrhal 
Cystitis (X 500). 
PC, Pus-corpuscles; CE, epithelia from the convoluted tubules of the kidney, contain- 
ing fat-globules; SE, epithelium from the straight collecting tubules of the kidney; UE, 
epithelium from the ureters; PE, epithelium from the pelvis of the kidney; MB, epithe- 
lium from the middle layers of the bladder; CT, connective-tissue shreds; FG, free fatr- 
globules; MT, mucus-strings. 



DISEASES OF THE KIDNEY AND PELVIS. 229 

the acute eruptive and inflammatory diseases, especially scarlatina, diph- 
theria, and pneumonia; less frequently typhoid fever and smallpox. It 
is occasionally seen during pregnancy, though it is not always easy to ac- 
count for its occurrence. Pressure produced by the gravid uterus may be 
partly responsible for it. In chronic affections, such as heart diseases, tu- 
berculosis, and syphilis, it may also be seen, as well as in rarer cases of 
malarial poisoning. 

As a result of strictures of the urethra, prostatitis, and hypertrophy 
of the prostate gland, parenchymatous nephritis is occasionally seen. 
The original inflammation is the cause of a cystitis, and, from the blad- 
der, it ascends to the ureters, pelves, and kidneys, ending in a paren- 
chymatous nephritis. A peculiar occurrence is its appearance in 
strong, healthy athletes during active training, especially when they 
subsist upon a meat diet; the same may be the case in fat people who 
desire to reduce their weight quickly by an exclusive meat diet. 

Clinical Symptoms. — The clinical symptoms vary with the intensity of 
the process, though anaemia, headache, loss of appetite, emaciation, nau- 
sea, and loss of strength are all generally present. Severe acute cases 
may be ushered in by chills, followed by a rise in temperature. Very 
soon oedema will appear, first being localized, especially on the eyelids, 
but soon becoming general, involving the face, hands, feet, and cellular 
tissues generally. To these symptoms will be added dull, aching pains in 
the lumbar region, and, in the severe cases, uraemic symptoms. 

Features Found in Urine. — Albumin is almost invariably present in 
comparatively large amount, and in some cases may be extremely abun- 
dant, reaching one-half of one per cent or even more. It is claimed that 
occasionally parenchymatous nephritis may exist without the presence 
of any albumin ; that albumin may exceptionally occur in small quan- 
tities only is undoubted, but it is probably never absent altogether, as 
careful tests for albumin will show. 

In acute parenchymatous nephritis the amount of urine is usually 
decreased, sometimes to a great degree, and in the severer and fatal cases 
may sink to a few ounces in the twenty-four hours, or may even be prac- 
tically suppressed. The specific gravity in in many cases higher than 
normal, often reaching 1.030 or more, and the color dark, being some- 
times quite pronounced, since hemorrhages frequently occur. The 
amount of solids, especially urea, voided during the twenty-four hours 
is usually decreased to a greater or less degree. In chronic nephritis 
the amount of urine is also at first decreased, but later becomes more 
abundant, though never in as pronounced a degree as in chronic inter- 
stitial inflammation. The specific gravity gradually becomes lower 
until in atrophy of the kidney it is never more than 1.012 or consider- 



230 URINARY ANALYSIS AND DIAGNOSIS 

ably less. The color varies, being pale in the later stages. The sedi- 
ment found in the urine is always quite abundant, and when once 
separated does not readily mix with the watery portion. 

As in interstitial nephritis, a positive diagnosis of croupous or paren- 
chymatous nephritis is in many cases possible only from a microscopical 
examination of the urinary sediment. This will vary considerably in 
acute, subacute, and chronic cases. In this variety of nephritis the pres- 
ence of casts in larger or smaller numbers is a constant feature, without 
which the diagnosis can never be made, and the greater the number of 
casts, the worse, as a rule, the inflammation. True casts will, however, 
never be found in urine without the presence at the same time of pus- 
corpuscles and kidney epithelia, the latter not only from the convoluted 
and narrow tubules, but frequently also from the straight collecting tu- 
bules, though these may be absent in mild cases. 

The varieties and sizes of the casts are of great importance for the 
diagnosis and prognosis. In strictly acute cases we will never find fatty 
or waxy casts, and only occasionally a few granular casts, while hyaline 
and epithelial casts are always present in larger or smaller numbers, and 
blood casts in the severer, hemorrhagic forms. Again, the severity of the 
process can easily be determined by the size of the casts — when the small- 
est casts from the narrow tubules alone are present in small numbers, the 
parenchymatous nephritis mil be of a mild character, and recovery is the 
rule. Casts from the convoluted and narrow tubules together, the former 
being of medium size, denote a process of moderate severity ; but as soon 
as the largest casts, coming from the straight collecting tubules, are pres- 
ent with the other varieties, we know that the inflammatory process has 
affected the whole kidney — that is, both cortical and pyramidal substance 
— and is a severe one; therefore, a doubtful prognosis only can be given. 

Acute Parenchymatous or Croupous Nephritis (Fig. 105). — When 
we examine the urine from a case of acute croupous nephritis, the features 
are found to be numerous and characteristic. The most pronounced ele- 
ments are undoubtedly the casts, which are seen in varying numbers in 
every field of the microscope. In such cases, two varieties of casts are 
usually found — the hyaline and the epithelial, the latter studded with 
epithelia to a greater or less degree. The more numerous the casts, the 
severer the inflammation and the more albumin the urine usually con- 
tains. 

Besides the casts, pus-corpuscles, red blood-corpuscles, and epithelia 
from the convoluted tubules are always present. They are found in mod- 
erate or large numbers, the kidney epithelia being frequently seen massed 
together. Red blood-corpuscles are found in every field, though, unless 
a hemorrhage has taken place, they cannot be called verv abundant. 




Fig. 105. — Acute Parenchymatous or Croupous Nephritis, with Pyelitis 
and Catarrhal Cystitis ( X 500) . 

RB, Red blood-corpuscles ; PC, pus-corpuscles ; CE, epithelia from the convoluted 
tubules of the kidney; ES, epithelium from the straight collecting tubules of the kidney; 
UE, epithelia from the ureter; PE, epithelia from the pelvis of the kidney; UB, epithelia 
from the upper layers of the bladder ; MB, epithelia from the middle layers of the bladder ; 
CC, creatinin crystals; HC, hyaline casts; EC, epithelial cast; MT, mucus- thread; MC, 
mucus-cast , CT , connective-tissue shred. 



DISEASES OF THE KIDNEY AND PELVIS. 233 

Epithelia from the straight collecting tubules may also be seen, and those 
from the ureter and pelvis of the kidney almost invariably accompany the 
other features. In some cases, there will also be an accompanying acute 
cystitis, shown by the presence of epithelia from the upper and middle 
layers of the bladder. 

In these acute cases, mucus is present in fairly large amount, the pale 
strings being sometimes of considerable size, irregular, and finely striated. 
Not infrequently mucus is found in the form of casts— the so-called cylin- 
droids. The presence of these has no further significance than the pres- 
ence of mucus in general, and they may be seen in inflammations of any 
one of the genito-urinary organs. When they exist in a characteristic form, 
they can hardly be mistaken, as they are always faintly striated; but not 
infrequently they are so faint that their striation becomes visible only 
upon sharp focusing, and caution is here necessary not to mistake them 
for hyaline casts, which is frequently done. In size and shape they may 
resemble hyaline casts, which latter, however, are never striated. When 
they assume an irregular, convoluted form their diagnosis is easy. 

In the severer cases of acute parenchymatous nephritis small shreds 
of connective tissue will be present; they are never large or numerous, 
and their higher refraction and pronounced fibrillary structure are suf- 
ficient to differentiate them from mucus. Besides these features, crys- 
tals of creatinin may be present in intense cases in which ursemic con- 
vulsions not rarely develop. The illustration is taken from a case of 
severe nephritis, which developed in the third week of scarlet fever and 
caused the death of the patient. The urine contained large numbers of 
characteristic creatinin lozenges and plates. 

Besides the cases just described, severe cases with pronounced hemor- 
rhages are often seen, and will give somewhat different features (Fig. 106). 

The urinary sediment contains a large number of red blood-corpuscles 
in every field, together with many blood casts. The blood casts are partly 
filled with red blood-corpuscles, which have retained their normal ap- 
pearance, and partly with disintegrated blood-globules, in the form of ir- 
regular brown masses, giving to the whole cast a rust-brown appearance; 
blood casts assume this character when they have been retained in the 
tubules for some time. Sometimes the larger portion of the cast contains 
fully formed red blood-corpuscles, while the disintegration has com- 
menced in a small portion. Besides these casts, hyaline and epithelial 
casts are found in large numbers, and in these cases we almost invariably 
find large casts from the straight collecting tubules. 

Epithelia from the straight collecting tubules are usually quite "abun- 
dant, and connective-tissue shreds are larger and more numerous than in 
the preceding. In an active hemorrhage such connective-tissue shreds 



234 URINARY ANALYSIS AND DIAGNOSIS. 

are cast off in fair numbers and found in the urine. Sometimes masses 
of fibrin are also found. The other features are the same, there being 
in most cases an accompanying inflammation of the pelves, the ureters, 
and the bladder. 

Subacute Parenchymatous Nephritis (Fig. 107). — After a croupous 
or parenchymatous nephritis has lasted for some time, the casts, or 
rather some of the casts, commence to change. Such a change is rarely 
noticed until four or six weeks after the commencement of the inflam- 
mation, but occasionally, especially in nephritis after scarlet fever in 
children, may take place in one or two weeks. 

The first change will be seen in the epithelial casts, some of the epi- 
thelia breaking down into granules, giving us an epithelial-granular cast. 
Very soon, however, perfect granular casts, without any trace of epithe- 
lia, are also found in small or moderate numbers, and these, in exceptional 
cases in children, can be seen as early as one week after the inflammation 
has started, being then scanty. 

The next change which takes place is the transition of the granules 
into glistening, refractive fat-granules and -globules, at first only two or 
three being noticeable in a granular cast, and later on a larger number. 
Traces of the original epithelia may still be seen in the cast, while the 
largest portion has become changed into granules, and some of the gran- 
ules into fat-globules, and we now have epithelial-granular-fatty casts. 
When the inflammation has lasted for six weeks or two months, small 
groups of free fat-globules, at first scanty, are also found, and a few glob- 
ules are seen in the epithelia. 

The other features, usually present in moderate numbers only, are 
the same as in an acute parenchymatous nephritis, and connective- 
tissue shreds are scanty, unless the case is a severe one. Mucus- 
threads and -casts may at times be pronounced, and the accompanying 
inflammations, especially in the bladder, are well marked. 

Chronic Parenchymatous Nephritis. — The longer a nephritis lasts, 
the more marked are the changes in the casts, and in strictly chronic 
cases neither hyaline nor epithelial casts are seen in the urine. The 
granular casts are the most abundant in the milder forms, though a few 
fatty casts or granular-fatty casts are also present. The groups of 
free fat-globules, as well as the fat-globules in the epithelia and pus- 
corpuscles become more numerous and more pronounced. 

In almost all cases of chronic croupous or parenchymatous nephritis, 
which have lasted for many months, and instead of abating have become 
more pronounced, a fatty degeneration of the kidney will develop, and we 
now have the so-called large white kidney (Fig. 108) . 

In these cases the fatty casts are abundant, and the large casts from 



© i 




© ® 



Fig. 106. — Acute Hemorrhagic Parenchymatous or Croupous Nephritis, 
with Pyelitis and Catarrhal Cystitis (X 500). 

RB, Red blood-corpuscles; PC, pus-corpuscles, CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelia from the straight collecting tubules of the kidney; 
UE, epithelia from the ureter ; PE, epithelia from the pelvis of the kidney ; UB, epithelia 
from the upper layers of the bladder ; MB, epithelia from the middle layers of the bladder ; 
HC, hyaline casts; EC, epithelial cast; BC, blood casts; CT, connective-tissue shred; 
MC, mucus-cast. 



& j§) © 
4-^ 




EGF 



Fig. 107. — Subacute Parenchymatous or Croupous Nephritis, with Pyelitis 
and Catarrhal Cystitis (X 500). 
RB, Red blood-corpuscle ; PC, pus-corpuscles ; CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelium from the straight collecting tubules of the kidney; 
UE, epithelia from the ureters; PE, epithelium from the pelvis of the kidney; UB, epi- 
thelia from the upper layers of the bladder; MB, epithelia from the middle layers of the 
bladder; HC, hyaline cast; EC, epithelial cast; GC, granular-cast; GF, granular-fatty 
cast; EGF, epithelial-granular-fatty cast; MT, mucus-thread; MC, mucus-cast; CT, 
connective-tissue shred; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 239 

the straight collecting tubules are frequently seen in conjunction with the 
smaller casts. The fatty changes in the pus-corpuscles and epithelia are 
well marked, and the groups of free fat-globules and -granules are large 
and numerous. Here, too, individual fat-globules, much larger than those 
ordinarily seen, and sometimes attaining three or four times their size or 
even more, may be present. In rare cases needles of margaric acid in 
small numbers are found, but these are exceptional. Red blood-corpus- 
cles are scanty in the majority of these cases. 

Connective-tissue shreds are usually present, but, as a rule, are small 
and not numerous. The evidences of chronicity, as shown by the fat- 
globules, will be seen in all epithelia found in the urine; that is, both 
those from the convoluted and straight collecting tubules of the kid- 
ney, from the pelvis, the ureters, and the bladder. The epithelia from the 
straight collecting tubules are sometimes numerous, and may be just as 
abundant as the cuboidal epithelia. Pelvic epithelia are rarely absent, 
and those from the ureters are well marked. That a cystitis of varying 
degrees of intensity is always present need hardly be mentioned. 

Besides the fatty degeneration, a waxy or amyloid degeneration of the 
kidney is found in a number of cases. Some authors call this an amyloid 
disease of the kidney, and claim that it is an independent affection and 
not associated with a parenchymatous nephritis. This view is undoubt- 
edly incorrect, as a waxy degeneration of the kidney is usually a second- 
ary affection found in chronic cases of nephritis. The exact cause and 
nature of such a degeneration are not known, and it is mostly found in 
chronic diseases, such as syphilis, tuberculosis, suppurative processes, 
ulcerations, and necroses. It seems to be due to some chemical 
change in the plasma of the blood, though the nature of this change is 
unknown. 

Waxy degeneration of the kidney may occur in both interstitial and 
parenchymatous nephritis; it is much more common in the latter, and is 
rare in the former. It invades the epithelia of the uriniferous tubules, 
and ultimately produces waxy casts. Epithelia which have become 
waxy are highly glistening, and are found in the urine as more or less 
shining, homogeneous bodies. Not only the epithelia, but also the con- 
nective tissue, and simultaneously the walls of the blood-vessels, may 
undergo waxy degeneration. 

The appearance of the urine is not characteristic of this degeneration, 
and it will present the features of a chronic nephritis, though the amount 
of sediment greatly varies, being sometimes slight, sometimes abundant. 
The specific gravity is usually low, and the amount of urine voided above 
normal. The diagnosis should never be made unless the changes in the 
urinary features are pronounced, and care must be taken not to mistake 



240 URINARY ANALYSIS AND DIAGNOSIS. 

hyaline casts, which may in rare cases be somewhat glistening, for waxy 
casts. 

In chronic parenchymatous nephritis with waxy degeneration of the 
kidney, the most characteristic features are the waxy casts (Fig. 109). 

Waxy casts may occur in all sizes, are always of a high refraction, 
have wavy, convoluted contours, and frequently a yellowish color. The 
casts may assume different forms, and not rarely are so tortuous as to be 
likened to a corkscrew. In most cases all the three sizes of waxy casts 
will be found, and they may sometimes be mixed with other elements, 
such as granules — the granular-waxy; or with fat-globules — the fatty- 
waxy casts. The other features are the same as those in any chronic 
croupous nephritis. Pus-corpuscles are always present, as well as differ- 
ent epithelia, connective-tissue shreds in large numbers, and granular as 
well as fatty casts. The appearance of a waxy degeneration is usually 
of grave import, though even here recoveries have occurred, especially 
in children. 

Cystic degeneration, which is also a secondary change, found in 
chronic cases of nephritis, does not give any characteristic symptoms in 
the urine, and, therefore, cannot be diagnosed as such. 

Atrophy of the Kidney. — The result of a chronic croupous or paren- 
chymatous nephritis is invariably atrophy of the kidney. The features 
of atrophy, as found in the urine, are characteristic, and a positive diag- 
nosis can always be made, though the amount of urine voided in the 
twenty-four hours varies, is never as abundant as in cirrhosis of the kid- 
ney, and is usually considerably below the normal amount. The features 
are the following: 

1. A continuously low specific gravity, as a rule never above 1.010, 
and occasionally not more than 1.006 or 1.004 at any time. 

2. The presence of a large amount of albumin, in contradistinction to 
the small amount found in cirrhosis. 

3. A considerable diminution of all salts. 

4. Pus-corpuscles, present in moderate numbers, many, if not all, con- 
taining fat-granules and -globules. 

5. Epithelia from the convoluted and straight collecting tubules of the 
kidney, in moderate numbers, many or all containing fat-granules and 
-globules. 

6. Free fat-granules and -globules, sometimes in large numbers. 

7. Granular, fatty, and in some cases even waxy casts in varying 
numbers, the former being usually quite abundant. 

8. Connective-tissue shreds of moderate or large size, and always in 
at least fair numbers. 

9. Red blood-corpuscles in varying numbers; these are practi- 




Fig. 108. — Chronic Parenchymatous or Croupous Nephritis with Fatty 
Degeneration of the Kidney, Accompanying Pyelitis and Catarrhal Cys- 
titis (X 500). 
PC, Pus-corpuscles; CE, epithelia from the convoluted tubules of the kidney; SE, 
epithelia from the straight collecting tubules of the kidney; UE, epithelium from the 
ureter; PE, epithelia from the pelvis of the kidney; MB, epithelia from the middle 
layers of the bladder; GC, granular cast, FC, fatty casts; GF, granular-fatty casts; 
CT, connective-tissue shreds; FG, free fat-globules. 



16 



wc 



UE' 



WF 




FC 

SE 



Fig. 109. — Chronic Parenchymatous or Croupous Nephritis, with Fatty 
and Waxy Degeneration of the Kidney, Accompanying Pyelitis (X 500) 

P, Pus-corpuscles; CE, epithelia from the convoluted tubules of the kidney; SE, 
epithelia from the straight collecting tubules of the kidney; UE, epithelia from the 
ureter; PE, epithelia from the pelvis of the kidney; GC, granular cast; GF, granular- 
fatty cast; FC, fatty cast; WC, waxy cast; WF, waxy-fatty cast; MC, mucus-cast; 
CT, connective-tissue shred; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 245 

cally never absent, though they usually are scanty. 

Epithelia from the pelvis of the kidneys, the ureters, and the middle 
layers of the bladder will be present in variable numbers. 

Here, again, attention must be called to the fact that a badly dis- 
eased kidney, as an atrophied kidney always is, can never void many 
salts. In those cases in which the specific gravity is higher, and uric- 
acid, calcium-oxalate, or phosphate crystals are seen under the micro- 
scope, though all the other features admit of a positive diagnosis of 
atrophy of the kidney, we can reach the conclusion that only one 
kidney is as yet severely affected, since the salts must be voided by 
the other kidney. While a nephritis is in the greatest number of cases 
bilateral, both kidneys being affected, it occasionally happens that 
one kidney is less severely affected than the other. For a variable 
length of time the second kidney may remain functionally fairly 
efficient. The prognosis in all such cases is considerably better than 
when no salts whatever are seen. 

Chronic Parenchymatous Nephritis, with Acute Parenchymatous 
Exacerbation. — In many cases of chronic parenchymatous nephritis, 
acute exacerbations may occur at any time, and fresh portions of the 
kidney tissue become inflamed. Such acute exacerbations can, in some 
individuals, be produced upon the slightest cause, as exposure to cold 
or errors in diet. It is not uncommon for an exacerbation of this kind 
to be produced every few weeks or months, leaving the patient weaker 
every time, and finally resulting in death. 

A case of this kind, in which an acute croupous hemorrhagic exacer- 
bation took place in a young man of twenty years, is shown in Fig. 110. 

In this case, which ended fatally, all six varieties of casts, and of all 
three sizes, were present in large numbers. Not only were the regular 
casts seen, but a number of different combinations. The casts present 
were hyaline, epithelial, blood, granular, fatty, waxy, granular-fatty, epi- 
thelial-waxy, blood-waxy, and fatty-waxy. 

Red blood-corpuscles were present in every field in moderately large 
numbers, and variously sized groups of fat-globules were also abundant. 
Pus-corpuscles were numerous, and epithelia from the convoluted as well 
as the straight collecting tubules of the kidney were present in large num- 
bers, many studded with fat-globules. Connective-tissue shreds were 
present, and mucus in the form of threads, and especially casts, could be 
seen in many fields. Of the accompanying inflammations, the pyelitis 
was the most severe, though the inflammations of the ureters and bladder 
were well marked. 

Salts were entirely absent under the microscope and the specific 
gravity was low. The diagnosis that probably both kidneys were affected 



246 URINARY ANALYSIS AND DIAGNOSIS. 

in a severe degree was made, and a bad prognosis had to be given. The 
patient died within two weeks after the examination. 

From the descriptions here given, it will be seen that the varieties of 
casts found in parenchymatous or croupous inflammations of the kidney 
tend to show whether the process is acute, subacute, or chronic. When 
hyaline, epithelial, or blood casts are found in a case giving all the symp- 
toms of chronicity, we can be certain either that an acute exacerbation has 
taken place in the same kidney or that the second kidney has become 
acutely inflamed. Sometimes cases of a so-called acute inflammation 
show granular and even fatty casts in large numbers, but careful ques- 
tioning of the patient will bring out the fact that he has not been perfectly 
healthy for a long time, though he may have been able to attend to his 
business in spite of headache and general malaise. The only cases in 
which purely granular casts in small numbers may occasionally be seen 
one or two weeks after the commencement of the inflammation, are those 
already mentioned, especially in children after scarlet fever. Waxy casts 
never appear in acute inflammations, but always denote chronicity. 

SUPPURATIVE NEPHRITIS. 

Suppurative nephritis, also called abscess of the kidney, or surgical 
kidney, the most intense of the three primary varieties of nephritis, is an 
independent process, and must not be confounded with acute interstitial 
nephritis or non-suppurative pyelo-nephritis. There may be either a 
number of small, disseminated foci of suppuration, or one large abscess, 
usually confined to one kidney. Sometimes the suppuration may be so 
excessive that the larger part of the structure of the kidney has disap- 
peared, and a large, thick-walled cavity filled with pus is found in its 
place; these cases are spoken of as pyonephrosis. 

Causes. — The causes of a suppurative nephritis are not always plain, 
though in many cases the disease is the result of an extension of the in- 
flammatory process from some other portion of the genito-urinary tract. 
A simple gonorrhoea, which gradually extends upward, may be sufficient 
to cause it, and both urethral strictures and inflammation and hypertro- 
phy of the prostate gland may be causes. The use of unclean sounds and 
catheters, even in these days of antisepsis, is not rarely followed by an 
abscess of the kidney. 

Occasionally the disease follows different acute infectious diseases, 
such as typhus and typhoid fevers, cholera, and diphtheria, or may be 
seen with pyaemia and carbuncles. In renal tuberculosis abscesses are 
quite common, and they may also occur when calculi are present. In 




Fig. 110. — Chronic Parenchymatous or Croupous Nephritis, with Fatty 
and Waxy Degeneration of the Kidney and an Acute Hemorrhagic 
Croupous Exacerbation, Pyelitis, and Catarrhal Cystitis (X 500). 
RB, Red blood-corpuscles; PC, pus-corpuscles; CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelia from the straight collecting tubules of the kidney; 
UE, epithelia from the ureter ; PE, epithelia from the pelvis of the kidney ; UB, epithelium 
from the upper layers of the bladder; MB, epithelium from the middle layers of the blad- 
der; HC, hyaline cast; EC, epithelial cast; BC, blood-cast; GC, granular cast; FC, 
fatty cast; FW, fatty-waxy cast; EW, epithelial-waxy cast; CT, connective-tissue shred; 
MT, mucus-thread; MC, mucus-corpuscle; C, mucus-cast; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 249 

still other cases the etiology remains obscure, and we can only surmise 
that pyogenic organisms in large numbers have settled in a perhaps pre- 
viously inflamed kidney. 

Clinical Symptoms. — Acute abscesses are usually ushered in by pro- 
nounced chills, followed by a rise in temperature and general depression. 
Pain, as a rule, is present, although it is not always referred to the seat of 
the abscess. Emaciation, nausea, and vomiting can occur. After an ab- 
scess has ruptured, it may continue to discharge pus for a long time, be- 
coming chronic. In these cases the acute symptoms gradually subside, 
though a slight fever is always present, and pain or tenderness either in 
the region of the kidney or in the inguinal region, testicles, or legs is a 
constant feature. 

Features Found in Urine. — The urine in suppurative nephritis is always 
cloudy, and a pronounced heavy sediment invariably forms. The spe- 
cific gravity varies considerably, but is mostly below normal, and the 
amount of urine is diminished. Albumin is present in large amount in 
every case. 

The clinical symptoms are at times so vague that a positive diagnosis 
is generally possible only through a microscopical examination of the uri- 
nary sediment. The features found under the microscope will at once 
clear up the diagnosis, and it does not seem necessary for the abscess to 
have ruptured; emigrated pus-corpuscles and the shedding of connective- 
tissue shreds are sufficient for a diagnosis as long as no firm membrane 
has formed around the abscess. 

The microscopical features are the presence of a large number of pus- 
corpuscles, many kidney epithelia, usually from both the convoluted and 
straight collecting tubules, and a varying number of red blood-corpuscles, 
the latter being quite abundant in acute abscesses. Besides these, con- 
nective-tissue shreds are always found, in either moderate or large amount. 
Without such shreds, abscess of the kidney should never be diagnosed, 
since these alone show a destruction of the kidney tissue. Epithelia from 
the pelvis of the kidney almost invariably accompany the affection. Casts 
may be either present or absent; when present, they denote a complicat- 
ing parenchymatous nephritis. 

The features seen in a chronic suppurative nephritis are shown in Fig. 
111. 

The pus-corpuscles are extremely numerous, and may so entirely fill 
some fields that no other features become visible. In other fields, how- 
ever, epithelia from the convoluted tubules of the kidney will be found in 
large numbers, and, as a rule, those from the straight collecting tubules 
are also present, Fat-globules and -granules are abundant, partly lying 
free in variously sized groups, partly fining the pus-corpuscles and epithe- 



250 URINARY ANALYSIS AND DIAGNOSIS. 

lia to a greater or less degree. Connective-tissue shreds are present, being 
large and abundant. 

Red blood-corpuscles are always found, but in such cases in small 
numbers only, while not infrequently rust-brown crystals of haematoidin, 
in the form of needles and plates, but especially the former, denoting a 
previous hemorrhage, are seen. These will be found in the pus-corpuscles 
and epithelia, as well as free. In the case depicted, the haematoidin crys- 
tals are very abundant, being found in the form of large conglomera- 
tions of irregular, curved needles and stars, as well as smaller plates. 
Epithelia from the pelvis of the kidney, the ureter, and the bladder, de- 
noting an inflammation of these organs, are also fairly numerous. In 
addition, numerous bacteria are usually present. 

Although these features are perfectly characteristic, we not infre- 
quently find another, the so-called endogenous new-formation of pus- 
corpuscles in different kidney and even pelvic epithelia, denoting, if pres- 
ent in large numbers, a pressure. Such a diagnosis will, therefore, hardly 
ever present any difficulties, contrary to the opinion frequently held that 
it is impossible to diagnose an abscess from the examination of the urine 
alone. 

Abscesses not directly in the kidney substance, but pressing upon the 
kidney — perirenal abscess — may also be diagnosed. These will show the 
same features in the urine, though perhaps somewhat less marked, to- 
gether with endogenous new-formations in the kidney epithelia. When- 
ever these are seen in many epithelia, they are caused by long-continued 
pressure upon the kidney, and their presence justifies the diagnosis. 

SUPPURATIVE PYELITIS. 

An abscess may develop in the pelvis of the kidney instead of in the 
kidney proper. The causes of this are the same as for suppurative nephri- 
tis, though perhaps calculi will more frequently produce an abscess here 
than in the kidney proper. The symptoms do not differ from those of 
suppurative nephritis, and the exact location of the abscess can only be 
determined by microscopical examination of the urine (Fig. 112). 

In an acute suppurative pyelitis, red blood-corpuscles are always pres- 
ent in moderate or even large numbers, and pus-corpuscles are extremely 
numerous. The diagnosis can be made from the cuboidal and irregular 
pelvic epithelia, which in these cases are abundant, and may be found in 
groups. In such abscesses epithelia from all the different layers of the 
pelvis will be present. These epithelia may vary considerably in size, and 
a few may be even as large as those from the middle layers of the bladder. 
There should, however, be no difficulty in diagnosing them, since these 



m ©o 




Fig. 112. — Acute Abscess of Pelvis of Kidney, or Acute Suppurative Pyelitis 

(X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; UE, epithelium from the ureter ; PE, 
epithelia from the pelvis of the kidney; CE, epithelia from convoluted tubules of the 
kidney; CT, connective-tissue shreds. 



DISEASES OF THE KIDNEY AND PELVIS. 253 

large epithelia are irregular, angular, lenticular, or pear-shaped. Connec- 
tive-tissue shreds are numerous, and without them no such diagnosis must 
be made. 

In all cases epithelia from the ureter, showing a secondary inflamma- 
tion, are quite abundant, and in many of them endogeneous new-forma- 
tions of pus-corpuscles will be found. Epithelia from the convoluted 
tubules of the kidney need not necessarily be present in acute cases, but 
sooner or later a moderate number, the indication of an accompanying 
nephritis, are seen; here, too, endogenous new-formations can appear. 
Very soon a cystitis will develop, and the epithelia from the bladder ac- 
company the other features. 

In a chronic abscess of the pelvis the features are the same as those 
described in suppurative nephritis, except that the comparative number 
of the pelvic and kidney epithelia becomes changed, the former being 
considerably more numerous than the latter. 

TUBERCULOSIS OF THE KIDNEY. 

Although renal tuberculosis can undoubtedly exist as a primary dis- 
ease, it is comparatively rare, being most frequently associated with tu- 
berculosis in other organs. It may result from an extension of the tuber- 
cular process from other portions of the genito-urinary tract. In the 
kidney we will generally find evidences of a chronic interstitial or catar- 
rhal nephritis, though in rare cases a parenchymatous or croupous in- 
flammation accompanies the tubercular process. The tubercular nodules 
in different portions of the kidney enlarge, and, after a time, usually break 
down, so that ulcers or abscesses are formed. 

Features Found in Urine.— The appearance of the urine is not charac- 
teristic in these cases; the color is usually pale, and it is turbid and of a 
low specific gravity. The amount of urine is increased, and a small 
amount, sometimes only a trace, of albumin is present. The sediment is 
slight, unless ulcers or abscesses have formed, when it is more profuse. 

The features under the microscope are at first those described in a 
chronic interstitial nephritis, and later on give evidences of a destructive 
process, with the presence of connective-tissue shreds in varying amount. 
In most cases a pronounced cystitis is associated with the process, and 
not rarely ulcers will be formed in the bladder. Such a chronic ulcerative 
cystitis should always be looked upon with suspicion, as being possibly 
due to a tuberculosis. 

Whenever tuberculosis is suspected in the kidneys, and the evidences 
of a chronic interstitial nephritis are found in the urine, examinations for 
tubercle bacilli must be made. This is not infrequently a tedious process, 



254 URINARY ANALYSIS AND DIAGNOSIS. 

as the bacilli are rarely present in large numbers; yet the diagnosis can- 
not be made with certainty without them. Repeated examinations of 
many drops, from urine taken at different times of the day, will never 
fail to reveal them. In exceptional cases they are quite numerous. 

It is of the utmost importance that a diagnosis of the presence of 
a renal tuberculosis be made as early as possible, the more so since, 
in contradistinction to nephritis generally, tuberculosis in many cases 
at first attacks one kidney only, and may remain confined to that 
kidney for a variable length of time. If the process continues, and 
the diseased kidney is not removed, an inflammation of the second 
kidney will surely set in, and impair its functional efficiency. Al- 
though renal tuberculosis is more frequently found in young individ- 
uals, it is occasionally seen in persons of middle age or beyond middle 
age. 

In every case in which there is any suspicion of the presence of 
tuberculosis of the kidney, ureteral catheterization should be resorted 
to, and the urine from each kidney examined separately for the pres- 
ence of tubercle bacilli. Examination of ureteral catheter urines is 
much more satisfactory, and tubercle bacilli are more readily found 
when present, than in a mixed bladder urine. When, in spite of a 
negative result, the symptoms persist, and urine examination distinctly 
shows an inflammatory condition of the kidney, guinea-pig inocula- 
tions should always be made. Often enough such inoculations alone 
will positively determine the presence or absence of a tuberculous 
process. 



WIS 




Fig. 111. — Chronic Suppurative Nephritis, with Catarrhal Pyelitis (X 500). 

RB, Red blood-corpuscle; PC, pus-corpuscles; CE, epithelia from the convoluted 
tubules of the kidney; SE, epithelium from the straight collecting tubules of the kidney; 
UE, epithelia from the ureter; PE, epithelia from the pelvis of the kidney; CT, con- 
nective-tissue shreds; HC, hsematoidin crystals; FG, free fat-globules. 



DISEASES OF THE KIDNEY AND PELVIS. 257 



II. ANOMALIES OF SECRETION. 

Of great importance in the diagnosis of kidney lesions are the anom- 
alies of secretion, under which term the conditions known as liihcemia and 
oxaluria are included. Sooner or later these will in many cases produce 
an inflammation of the kidney proper, as well as the pelvis of the kidney, 
and may in pronounced cases cause hemorrhages from the kidney and 
pelvis, as well as abscesses. 

Both lithsemia and oxaluria are of frequent occurrence, and need not 
of necessity lead to the production of calculi, though this may occur. 
Persons so affected will pass large quantities of uric acid or calcium oxa- 
late, or both, and their urine almost invariably has a high specific gravity. 

Causes. — The causes of these conditions are practically unknown. It 
was believed that persons who live high, eat an excessive amount of 
meat as well as starchy and saccharine substances, and drink considerable 
champagne are predisposed to the so-called uric-acid diathesis. This is 
undoubtedly true in some cases; but in others just the opposite condi- 
tions prevail, and still uric acid is voided in large amounts. 

Clinical Symptoms. — The clinical symptoms in these cases, which are 
much the same in both conditions, are headache, general malaise, dys- 
pepsia, irregularity of the bowels, sleeplessness, neurasthenia, and later on 
melancholia. Frequent urination with a burning sensation in the urethra 
may be present, and there is often a dull, aching feeling in the lumbar 
region. In lithsemia fleeting pains in legs, knees, hands, and arms may 
also exist. Persons so affected are always irritable, and sooner or later 
suffer from neurasthenia and melancholia; they may be treated for a va- 
riety of affections before the true cause of their condition is discovered. 



LITHCEMIA. 

The microscopical features in the urinary sediment of a person affected 
with lithsemia are quite characteristic (Fig. 113). 

Crystals of uric acid are found in large numbers, and as a rule different 
varieties, such as the common form, that seen in highly acid urine, and 
irregular plates and needles, are present. The crystals may attain large 
sizes, but usually the smaller sizes only are met with. Besides these, 
crystals of calcium oxalate in moderate numbers are also present. In 
many cases which come under observation pus-corpuscles are found in 
small or moderate numbers, as well as different epithelia, more especially 
those from the pelvis of the kidney and the ureters, though epithelia from 
the convoluted tubules in small numbers and bladder epithelia are rarely 

17 



258 URINARY ANALYSIS AND DIAGNOSIS. 

absent. Red blood-corpuscles are not numerous when no hemorrhage has 
taken place, though a few are always seen. A few fat-globules are usually 
seen in the pus-corpuscles and epithelia. 

In these, the common cases of lithsemia, we have, therefore, an in- 
flammation of moderate severity only, either a simple pyelitis or a pyelo- 
nephritis, with an accompanying cystitis. The inflammation, when seen, 
is rarely acute, but usually subacute or chronic. Such a condition may 
go on for many years without producing any other features. 

When large numbers of these salts are continually produced and de- 
posited in the pelves and calices of the kidneys, smaller or larger concre- 
tions or calculi will then be formed, and cause more pronounced symp- 
toms. In such cases the first symptom is not infrequently a hemorrhage 
from the kidney or pelvis, with more or less severe pain. All the features 
of such a hemorrhage, together with concretions of uric acid, will be found 
in the urine. After a day or two the symptoms may subside, but, if the 
causes leading to the formation of the salts still continue, will recur sooner 
or later. 

Hemorrhage from the Pelvis of the Kidney. — Hemorrhage from the 
pelvis of the kidney, due to uric-acid calculus, gives characteristic feat- 
ures in the urine, from which the diagnosis can easily be made (Fig. 114). 

The field is crowded with red blood-corpuscles, which vary very con- 
siderably in shape, size, and appearance. As the urine is usually not ex- 
amined until a number of hours after it is voided, comparatively small 
numbers will be found containing haemoglobin, and they are therefore of a 
yellowish or slightly brown color. The larger numbers usually have lost 
the haemoglobin, and these corpuscles will appear colorless, with a distinct 
double contour. They are found either singly or conglomerated in large 
groups. Crenated red blood-corpuscles are frequently found, but in small 
numbers only, and they may also be seen edgewise. When they have im- 
bibed water, they swell, and may be even double their usual size. Again, 
a varying number of haBmatoblasts, which present the features of red 
blood-corpuscles, but are only half their size, are often seen in an active 
hemorrhage. White blood-corpuscles, which may be twice the size of the 
fully formed red blood-globules, and cannot be distinguished from pus- 
corpuscles, are present in small numbers. They are always granular, 
either pale with a fine granulation or more glistening and having a coarser 
granulation. When comparatively few of these corpuscles are seen, we 
know that they are not pus-corpuscles, and their presence should never 
cause the diagnosis of an inflammation. 

Besides the blood-corpuscles, uric-acid crystals, in the form of irregu- 
lar plates, masses, and needles, are abundant. They vary considerably 
in size, are always colored, and may be either single or conglomerated. 




Fig. 113. — Litelemia, with Subacute Pyelitis and Catarrhal Cystitis ( X 500). 
UA, Uric-acid crystals; OC, calcium-oxalate crystals; RB, red blood-corpuscle ; PC, 
pus-corpuscles; PE, epithelia from the pelvis of the kidney; UE, epithelium from the 
ureter; UB, epithelium from the upper layers of the bladder; MB, epithelium from the 
middle layers of the bladder. 



DISEASES OF THE KIDNEY AND PELVIS. 261 

The needles may be seen in groups containing individual small formations, 
which sometimes appear like small granules, or they are large and form 
stellate masses. These are the forms which, when small, produce gravel; 
when large, are portions of calculi, and may lodge in the pelvis of the 
kidney. 

Epithelia from the pelvis of the kidney, varying in size but always 
characteristic, are more or less numerous. When the hemorrhage is se- 
vere, many fields may sometimes have to be examined before they are 
discovered, and the place of origin of the hemorrhage becomes clear; but 
they are always present, often in groups of three, four, or more. Smaller 
epithelia from the ureter are also seen. Connective-tissue shreds are 
never absent, though their number and size may be small. In pronounced 
cases they are usually found in large numbers. 

Besides these features, variously sized masses of fibrin, in the form of 
thin, pale, often colorless strings, consisting of wavy bands, may some- 
times be seen, and irregular clots of blood can also be found. In such 
hemorrhages all the features, including the epithelia and connective-tis- 
sue shreds, may occasionally have a yellowish color from the haemoglobin; 
but this is not the rule, unless the centrifuge has been used and the exam- 
ination made immediately after the urine is passed. 

Pyelitis Calculosa. — In the so-called pyelitis calculosa, an inflamma- 
tion or even suppuration of the pelvis is present, and due to calculi, the 
most common of which are uric acid and calcium oxalate, though phos- 
phatic stones are also not rare. The features are the same as those found 
in any catarrhal or suppurative pyelitis, with the addition of concretions. 
Red blood-corpuscles are invariably present in such cases, but, unless a 
hemorrhage occurs in the course of the inflammation, never in large 
numbers. 

OXALURIA. 

Among the anomalies of secretion, oxaluria plays an important part. 
It is far more common than is generally supposed, and in all cases giving 
vague neurasthenic symptoms the urine should be examined. The spe- 
cific gravity is usually high, varying between 1022 and 1030 or higher, 
and the amount of urine passed may be considerably below the normal. 
The microscope always shows large numbers of crystals of calcium oxa- 
late, in all shapes and sizes, and even in the milder cases an irritation of 
the pelvis of the kidney is rarely absent, so that a small number of pus- 
corpuscles and pelvic epithelia is found. Instead of an irritation, all the 
grades of inflammation may at different times exist, though oxaluria 
alone, without the presence of a stone, does not cause suppuration. 

When many crystals are present, minute concretions, which are so small 



262 URINARY ANALYSIS AND DIAGNOSIS. 

as to give no special symptoms, are frequently passed, and these, in a 
few cases, may cause hemorrhages from the pelvis. In a number of cases 
which have come under observation, prolonged hsematuria existed, but 
the cause could not be discovered, as there was no pain connected with it 
and no symptom to suspect the presence of a calculus. Microscopical ex- 
amination showed those minute concretions, and easily cleared up the 
case. 

HEMOGLOBINURIA. 

Hsemoglobinuria is a rare condition, which is characterized by a dis- 
solution of the red blood-corpuscles and the appearance in the urine of 
the coloring matters of the blood in solution. The red color of the urine 
which is always found in these cases is, therefore, not due to the presence 
of a large number of red blood-corpuscles, as in hsematuria, but to that 
of dissolved haemoglobin. 

Causes. — The affection is occasionally seen after poisoning with differ- 
ent substances, such as carbolic acid, sulphuric acid, naphthol, muriatic 
acid, pyrogallic acid, and even chlorate of potash. It may occur in the 
course of severe infectious and contagious diseases, such as hemorrhagic 
variola, malignant scarlatina, and yellow fever, as well as in intense mal- 
aria. After extensive burns, in scurvy, and purpura it has also been 
described. 

Besides these, it may occur as an idiopathic disease of intermittent 
character — the paroxysmal hsemoglobinuria — which is said to develop 
sometimes in rare cases of syphilis. In such cases urine containing haemo- 
globin may be voided either for a few hours only, or more rarely for days 
or even weeks, accompanying symptoms much like those of intermittent 
fever. As a rule, attacks of this kind follow exposure to cold. 

Features Found in Urine. — The appearance of the urine in hsemo- 
globinuria is always dark red or brownish, the sediment being abundant. 
The specific gravity varies considerably, but, as a rule, is slightly in- 
creased. Albumin will be found in varying amount. Although the dis- 
ease is by no means a distinct kidney affection, changes having taken 
place in the blood, a nephritis of varying degrees of intensity usually ac- 
companies it, and its features are found in the urine. 

The microscopical elements in a pronounced case of hsemoglobinuria, 
which occurred in yellow fever, are illustrated in Fig. 115. 

The urinary sediment contains an extremely large number of dark or 
rather rust-brown masses, made up of granular matter, as well as gran- 
ules scattered irregularly over the field. The masses vary considerably 
in size, some being small, but others large, and may assume different 
shapes; these are the masses and granules of haemoglobin. 



UA 



WC 



UA 




UA 



Fig. 114. — Hemorrhage from Pelvis of Kidney, Due to Uric- Acid Calculus 

(X 500). 
UA, Uric-acid crystals; RB, red blood-corpuscles; WC, white blood-corpuscle ; PE, 
epithelia from the pelvis of the kidney ; UE, epithelium from the ureter ; EC, epithelium 
from the convoluted tubules of the kidney ; CT, connective-tissue shreds. 



CEH 



EHO 




Fig. 115. — Hemoglobinuria, Acute Hemorrhagic Croupous or Parenchymatous 
Nephritis, with Catarrhal Pyelitis ( X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; H, haemoglobin ; CE, epithelia from the 
convoluted tubules of the kidney; SE, epithelium from the straight collecting tubules of 
the kidney; CEH, epithelia from the convoluted tubules, filled with haemoglobin; PE, 
epithelia from the pelvis of the kidney ; UE, epithelia from the ureter ; H C, haemoglobin 
cast; BC, blood cast; EHC, epithelial cast filled with haemoglobin; CT , connective- tissue 
shred; CH, cylindroid with haemoglobin; OC, calcium oxalate crystals. 



DISEASES OF THE KIDNEY AND PELVIS. 267 

Haemoglobin is also found in the form of casts, which appear filled 
with dark brown granules, but differ from blood casts by their greater ir- 
regularity. The latter are rarely absent, though the blood-corpuscles are 
never found fully formed in the casts, but always disintegrated, and of a 
rust-brown color. Epithelial casts are frequently present and are also 
studded with haemoglobin. 

Red blood-corpuscles are never entirely absent in these cases, though 
they are comparatively scanty, and always, even in the freshly voided 
urine, appear very pale and double contoured, having completely lost 
their coloring matter. 

Besides these features, pus-corpuscles and epithelia are present, many 
of which are entirely filled with granules of haemoglobin and have a dark 
brown color. Pus-corpuscles are fairly abundant, and epithelia from the 
convoluted and straight collecting tubules of the kidney are seen in mod- 
erate numbers. Epithelia from the ureters and the pelves of the kidneys 
are constant occurrences. 

Connective- tissue shreds are usually found, and may contain some 
granules of haemoglobin upon them. Mucus in the form of threads or 
casts may be present, studded with masses of haemoglobin. In those cases 
different salts, especially crystals of calcium oxalate and uric-acid crys- 
tals, are seen. In cases which have lasted a long time needles and plates 
of haematoidin may be found. 

CHYLURIA. 

Chyluria is characterized by the milky-white appearance of the urine, 
similar to milk or to chyle; this appearance it retains on account of the 
molecular division of the fat which it contains, even if left standing for 
days. In some cases, though not in all, chylous urine has a pink tinge, 
due to the red blood-corpuscles frequently present. 

Two varieties of the affection are recognized: The first, or tropical 
form, occurs almost exclusively in hot climates, and is due to an invasion 
of the blood and urinary tract by a parasite — the Filaria sanguinis hom- 
inis; the second, or non-tropical form, is not due to a parasite, and is so 
rare that but little is known about it. 

In most cases chylous urine contains coagula, due to a large amount 
of fibrin which is usually present. These clots form in the bladder, and 
may be so abundant as to give rise to distressing symptoms when voided. 

The features of a chylous urine are illustrated in Fig. 116. The case 
from which the illustration was drawn was that of a young man, thirty- 
three years of age, a native of Porto Rico, who had lived in the United 
States for nine years. Three years before he presented himself for exam- 



268 VEIN ART ANALYSIS AND DIAGNOSIS. 

ination he went to his native country for two weeks, and then returned 
to the United States. Two months after returning he noticed a milky 
appearance of his urine. The urine cleared up after a short time, and 
remained clear for more than two years, when it again became milky. 
The only symptoms he complained of, when he first came under observa- 
tion, were pain in the back and a slight frontal headache. In appearance 
the patient was thin and delicate-looking. Upon physical examination 
nothing could be discovered except a slightly enlarged liver. 

Features Found in Urine. — The appearance of the urine was that of 
milk in which slightly colored, pink coagula were suspended. The clots 
were numerous and greatly varied in size, the largest being removed from 
the bottle with difficulty. They had various shapes, some resembling 
cysts. The specific gravity was 1.015, the reaction slightly acid, and the 
urine contained one-half of one per cent of albumin. 

Under the microscope the clots proved to be masses of fibrin, em- 
bedded in wmich large numbers of red blood-corpuscles were found, and, 
in a few, also small plates of hsematoidin. In every field not obscured by 
the fibrin, red blood-corpuscles were very abundant, lying in groups, as 
well as singly, partly of a yellowish color, containing haemoglobin, and 
partly colorless. Crenated red blood-corpuscles were present in moderate 
numbers, and many were seen edgewise. 

Besides these, minute fat-globules and -granules were extremely nu- 
merous, partly in smaller or larger masses, partly lying irregularly through- 
out the field. Nowhere could larger fat-globules be seen. In some of the 
drops examined a number of parasites, the embryonal forms of the Filaria 
sanguinis, could easily be discovered; they were of different sizes. In 
one drop a group of five, embedded in or perhaps surrounded by a mass 
of fat-globules, was found. One small body, apparently an ovum, was 
also seen. 

The other features were pus-corpuscles and epithelia from the ureters 
and the middle layers of the bladder. Neither the pus-corpuscles nor the 
epithelia were found in every drop, it being necessary to examine a num- 
ber of drops before they were seen. Connective-tissue shreds were pres- 
ent, though not in every drop. No salts whatever could be discovered 
under the microscope. 




Fig. llG.^^bU^'LURiA, Catarrhal Cystitis (X 500). 
FG, Free fat-globules; RB, red blood-corpuscles; F, fibrin, with red blood-corpuscles 
and hsematoidin crystals; FS, Filaria sanguinis; PC, pus- corpuscles; UE, epithelium from, 
the ureter ; MB, epithelia from the middle layers of the bladder ; CT, connective-tissue 
shred. 



DISEASES OF THE KIDNEY AND PELVIS. 271 



III. MALIGNANT TUMORS OF THE KIDNEY. 

Malignant tumors of the kidney are fortunately rare, but do occur, 
and both sarcomata and carcinomata are met with. The former may be 
found at all ages, while the latter, which in the kidneys seem to be of 
still rarer occurrence than sarcomata, are usually seen in persons more 
advanced in years. The diagnosis of sarcoma of the kidney can be posi- 
tively made from the examination of the urine, while that of cancer 
might perhaps be suspected, but can hardly be made with the same de- 
gree of certainty as when it occurs in the bladder. 

Clinical Symptoms. — When a malignant tumor has lasted for some 
time, the clinical features will become pronounced enough to lead one at 
least to suspect its presence, but in the early stages its symptoms are not 
well denned; though even at this time characteristic features may be 
found in the urine. Pain, referred either to the region of the affected 
kidney or, less clearly defined, radiating to neighboring organs, will usu- 
ally be the earliest symptom. It is mostly of a severe character, and 
may be paroxysmally increased. 

Very soon a tumor in the region of the kidney can be mapped out, the 
patient becomes anaemic and cachectic, and gradually loses strength. If 
not relieved by surgical procedures, the general symptoms become more 
pronounced, and the disease, as a rule, ends fatally within one or two 
years, although cases of sarcoma which have lasted four or five years are 
on record. 

Appearance of Urine. — The appearance of urine is not character- 
istic. Since symptoms of inflammation soon develop, the specific grav- 
ity, color, and amount of urine voided will vary with the intensity of the 
inflammation. Hemorrhages, either constant or recurring at irregular in- 
tervals, soon appear, and the urine then has the pronounced reddish or 
brown color, due to the blood. Albumin is always present in varying 
amount. 

SARCOMA. 

Sarcoma of the kidney may be found in children as well as in adults, 
the youngest case seen by the author and diagnosed from the urine hav- 
ing been in a boy of four years, the oldest in a man of sixty-five years. 
Although the macroscopic al appearance of the urine may vary consider- 
ably, the microscopical features are usually characteristic enough to ad- 
mit of a positive diagnosis. In two cases the examination of the urine 
gave the first evidence of the disease, the clinical symptoms of the pa- 
tient not being at first clear; by careful examination of the patient, how- 



272 URINARY ANALYSIS AND DIAGNOSIS. 

ever, a tumor of the kidney could soon be mapped out, and further de- 
velopments proved the correctness of the diagnosis. 

Features Found in Urine. — That sarcoma of the kidney can be diag- 
nosed from the urine was first shown by Carl Heitzmann, and a number 
of cases were published by him in the year 1888. Since then other cases 
have been seen by the author, and autopsies have left no doubt of the 
correctness of his assertions. In order positively to diagnose sarcoma, we 
must find large shreds of connective tissue as well as numerous character- 
istic sarcoma corpuscles in the urine, and therefore an ulceration must 
have taken place. It is not impossible that these corpuscles may appear 
in the urine before ulceration has set in, perhaps by emigration; but un- 
less they are very numerous, a positive diagnosis should not be given if 
large connective-tissue shreds are not found at the same time. It is well 
known that pus-corpuscles not only vary in size in different individuals, 
but also to a certain degree in the same individual, and that pus-corpus- 
cles, which are as yet not fully formed and appear as small, compact, or 
vacuoled bodies, may be found. These should not be mistaken for sar- 
coma corpuscles. 

The features found in a urinary sediment in sarcoma of the kidney are 
depicted in Fig. 117. 

We see extremely large shreds of connective tissue, which in places 
appear more coarsely granular than usually, and may form regular coils in 
different portions. Occasionally these shreds will contain a small number 
of inflammatory corpuscles. Besides the shreds, small, globular, coarsely 
granular, glistening, even homogeneous corpuscles, in which the nuclei 
are not seen on account of the coarse granulation, larger than red blood- 
corpuscles and smaller than pus-corpuscles, are found in large numbers; 
these are the sarcoma corpuscles. They are not only found singly, 
scattered throughout the field, but in variously sized, sometimes 
large groups. These corpuscles are so different in appearance from 
the larger, in these cases almost invariably pale pus-corpuscles, as to 
become noticeable at first glance. Being the elements seen in the 
tumor, they will never appear in any other disease. 

Besides these features, we find the evidences of a more or less severe 
inflammation, either with or without hemorrhage. In the case under 
consideration, red blood-corpuscles were not numerous, but pus-corpus- 
cles were present in fairly large numbers, many containing fat-globules, 
showing chronicity. These pus-corpuscles were almost without exception 
finely granular, and in some one or more nuclei were plainly visible, 
their appearance being different from the sarcoma corpuscles. Epi- 
thelia from the convoluted as well as the straight collecting tubules of 
the kidney, many containing fat-globules, were present in large num- 



sc 



FG 



UE 



RB 
MB 

CT 






15 






■• ■••••© • © 



sc 




Fig. 117. — Sarcoma of Kidney, Chronic Pyelitis and Catarrhal Cystitis 

(X 500). 

RB, Red blood-corpuscles ; PC, pus-corpuscles ; SC, sarcoma corpuscles ; CE, epithelia 
from the convoluted tubules of the kidney; SE, epithelium from the straight collecting 
tubules of the kidney; UE, epithelia from the ureter; PE, epithelia from the pelvis of the 
kidney; MB, epithelia from the middle layers of the bladder; CT, connective-tissue 
shreds; FG, free fat-globules. 



IS 



DISEASES OF THE KIDNEY AND PELVIS. 275 

bers, and groups of free fat-globules were also quite abundant. Epi- 
thelia from the pelvis of the kidney could be seen, and in many of 
them the endogenous new-formations of pus-corpuscles, indicating 
pressure, were present. Epithelia from the ureter and the middle 
layers of the bladder completed the features. 

Not infrequently a parenchymatous nephritis may be present, and 
then casts, especially of the granular and fatty variety, will be found. 



CANCER. 

In cancer of the kidney, a positive diagnosis cannot be made so easily 
from the simple examination of the urine. When a large number of ir- 
regular connective-tissue shreds, containing inflammatory corpuscles, and 
perhaps also larger, coarsely granular, frequently multinucleated epithelia 
are found, together with all the evidences of a chronic inflammation, can- 
cer can undoubtedly be suspected, and the clinical symptoms will soon 
clear up the diagnosis. In rare cases we may find distinct cancer 
nests, similar to those to be described in cancer of the bladder. 



CHAPTER XVII. 

DISEASES OF THE BLADDER. 
I. INFLAMMATIONS OF THE BLADDER. 

According to the degrees of intensity, inflammation of the bladder — 
cystitis — may be divided into catarrhal, suppurative, and ulcerative. 
The inflammation may be either acute, subacute, or chronic, and may af- 
fect either small portions of the mucous membrane of the bladder only, 
or almost the whole. 

The pathological changes in catarrhal inflammation of the bladder 
are the same as those found in any mucous membrane, and have been 
described in the previous chapter. In severe inflammations ulcers may 
be formed, which may become quite extensive, and in rare cases even 
lead to perforation. Occasionally abscesses will form in the wall of the 
bladder. 

Causes. — The causes of a cystitis, which may be either primary or sec- 
ondary, are numerous. Primary cystitis may be due either to exposure 
to cold, to chemical irritation, or to traumata. That a simple exposure 
to cold may cause a cystitis, often quite severe in character, cannot be 
denied. Among the chemical irritants different remedial agents, such as 
turpentine, copaiba, cantharides, and strong mineral acids, may be men- 
tioned. Alcoholic stimulants in large amount may cause mild attacks, as 
well as certain articles of diet, such as asparagus. 

One of the most common causes of cystitis is the passage into the 
bladder of instruments, such as catheters or sounds, which have not been 
thoroughly disinfected, so that pyogenic bacteria are introduced in large 
numbers. Again, traumata of different kinds are often responsible for 
the development of a cystitis. 

Secondary cystitis is at least as frequent as the primary form, and is 
often due to an extension of the inflammatory process from one or other 
of the genito-urinary organs. Gonorrhoea is a common cause of cystitis, 
in the first days of the disease as well as later on. Prostatitis, hypertro- 
phy of the prostate gland, seminal vesiculitis, vaginitis, cervicitis, and 
parametritis, as well as perimetritis, may all cause it. Again, inflamma- 
tions of the bladder may be produced by an inflammation of the kidney, 

276 



DISEASES OF THE BLADDER. 277 

pelvis, and ureter, the process gradually extending downward. Indeed, 
it is rare that a secondary cystitis, though mild in character, does not 
accompany a nephritis or pyelo-nephritis, even in acute cases. In chronic 
cases, such an accompanying inflammation is always present. 

That other affections of the bladder, such as tumors or calculi in the 
bladder, will soon cause an inflammation, is evident. In many other dis- 
eases, such as the different infectious and contagious diseases, it may occur 
at any time. Retention of the urine must be looked upon as an important 
cause. 

In most cases, though not necessarily in all, micro-organisms in vary- 
ing numbers will be present. In the mild acute cases, they may be absent 
entirely, or be present in small numbers only, while in the more pro- 
nounced cases they are always numerous. As a rule, both cocci and ba- 
cilli are found, though one or the other may predominate or even exist 
alone. The varieties of the micro-organisms which may be present in the 
bladder cannot always be determined, since some of those seen when the 
urine is examined are undoubtedly of secondary origin. Among the 
cocci, the different staphylococci — staphylococcus pyogenes aureus, 
albus, and citreus — as well as the streptococci pyogenes are common. 
The micrococcus ureae is often found in large numbers, and a variety 
of sarcina, called sarcina urinae, somewhat smaller than the usual form, 
is not rarely seen. In gonorrhoea) cystitis, the gonococcus is present. 

Among the bacilli, the bacillus coli communis, the typhoid bacillus, 
the bacillus ureaB, and the urobacillus liquefaciens septicus, occur. In 
some cases leptothrix threads are abundant. It has been claimed that 
the bacillus coli communis is more frequently found in cystitis than any 
other one bacillus, though the number of bacilli described is quite large. 

In the cases of so-called bacteriuria, bacteria of various forms may be 
present in enormous numbers in the bladder, and their origin cannot 
always be determined. It is certain that bacteria alone will not cause 
cystitis, but when an irritation of some kind exists they can set up a se- 
vere inflammation. The reaction of the urine does not necessarily need 
to be alkaline when micro-organisms have developed; but on the con- 
trary, some, as the bacillus coli communis, are frequently found with 
an acid reaction. 

Clinical Symptoms. — The symptoms seen in cystitis vary considerably 
with the severity and acuteness of the attack. An intense acute inflam- 
mation may be ushered in by chills, followed by moderately high fever 
and all the concomitant symptoms of the same. In milder cases fever 
will not be present. Frequent micturition invariably exists; this varies 
considerably with the intensity of the inflammation, and in the severe 
cases there is a constant desire to urinate, although only a few drops may 



278 URINARY ANALYSIS AND DIAGNOSIS. 

be voided at a time. More or less intense pain is never absent. The pain 
may be most pronounced at or just before the beginning of micturition, 
be somewhat diminished during the flow of urine, and again become more 
severe at the end of micturition. At other times the flow of urine seems 
to increase the pain, which is diminished immediately after. A certain 
amount of pain or discomfort almost invariably exists irrespective of 
urination, and may radiate to the back, thighs, scrotum, and penis. It 
may be most severe in the perineum. Pressure upon the bladder, as well 
as the passage of a catheter or other instrument, always causes more 
suffering. 

In chronic cases which are comparatively mild in character, frequent 
micturition, sometimes not very pronounced, with a feeling of discom- 
fort, may be the only symptom. When a cystitis has lasted for a long 
time the coats of the bladder become thickened, sometimes to a great 
degree. In such cases the bladder is never entirely emptied, and incon- 
tinence may exist, so that the urine will dribble away continually. 

Appearance of Urine. — The appearance of the urine varies. In the 
mild cases, when few or no bacteria are present, it may be perfectly trans- 
parent; but as soon as bacteria in moderate or large numbers have de- 
veloped, it is more or less turbid. The specific gravity also differs, being 
normal in mild cases and increased or diminished in the severer forms. 
Albumin is never entirely absent in these cases, since, it will always be 
found whenever pus-corpuscles are seen in the urine. In mild cases, how- 
ever, no more than a trace, sometimes very faint, can be discovered, while 
in the more intense cases it may exist in large amount. The reaction of 
the urine may be acid or alkaline. In mild acute cystitis, even when a 
few bacteria are seen, it may be acid, though, as a rule, only faintly so. 
In chronic cases, on the other hand, the urine is always more or less alka- 
line, and the alkalinity may be marked. 

CATARRHAL CYSTITIS. 

Microscopical Features. — The microscopical features in cystitis differ 
in the acute and chronic cases, as well as with the intensity of the inflam- 
mation, and are always characteristic on account of the presence of blad- 
der epithelia. Pus-corpuscles, epithelia from the bladder, and mucus- 
threads are never absent, though their amount differs in the different 
cases. 

Acute Catarrhal Cystitis (Fig. 118). — In an acute catarrhal cystitis 
of moderate severity the reaction of the urine may still be slightly acid, 
and salts will usually be found under the microscope, though they are not 
abundant. Those most commonly seen are crystals of calcium oxalate of 




Fig. 118. — Acute Catarrhal Cystitis (X 500). 
RB, Red blood-corpuscles; PC, pus-corpuscles; O, calcium oxalate; UA, ammonium 
urate; UB, epithelia from the upper layers of the bladder; MB, epithelia from the middle 
layers of the bladder; MT, mucus-threads; MC, mucus-corpuscles; CB, bacilli and cocci. 



DISEASES OF THE BLADDER. 281 

different sizes, present in almost every field. Even in those cases, how- 
ever, which still give an acid reaction, globules of ammonium urate partly 
the dumb-bell form of ammonium urate in statu nascenti, partly small, 
but fully formed globules, are seen. 

Pus-corpuscles are never absent, as without them no diagnosis of in- 
flammation is possible; but their number varies, and the mildest cases 
show perhaps only two, three, or four in every field. The more intense 
the inflammation, the more numerous are the pus-corpuscles. Red blood- 
corpuscles are present in every case of acute cystitis, and also vary in 
number to a great degree, but, unless hemorrhages have occurred, are 
never abundant. In hemorrhages, which are rare in these acute cases 
and are usually found only when the cystitis is due to calculi, tumors, 
parasites, or a severe trauma, the red blood-corpuscles may be so abun- 
dant as to obscure the other features. 

The diagnosis of a cystitis depends entirely upon the presence of the 
characteristic epithelia from the different layers of the bladder. As pre- 
viously explained, the bladder has stratified epithelium, the different 
strata of which contain different epithelia. The upper layers are lined 
with flat, the middle with cuboidal, and the deepest covering, one layer 
only, with columnar epithelia. The flat epithelia are desquamated in per- 
fect health, though to a small degree only, and when these are present 
alone in the urine, without any pus-corpuscles or cuboidal epithelia, the 
diagnosis of cystitis must never be made. As soon as the cuboidal epi- 
thelia are found, we can be certain of a pathological process in the blad- 
der; the more pronounced, the more numerous they are. 

In an acute catarrhal cystitis the flat epithelia from the upper layers 
and the cuboidal from the middle layers are always present together, and 
the more flat epithelia we find in comparison with the cuboidal, the milder 
the case. In such cases pus-corpuscles are scanty. When the flat and 
cuboidal epithelia are present in equal numbers, the inflammation is not 
very severe, but when the cuboidal epithelia are more abundant than the 
flat, pus-corpuscles will also be more numerous and the inflammation is 
more intense. We do not expect to find columnar epithelia, unless the 
inflammatory process has extended to the deepest layer, and has become 
very pronounced. 

The sizes of the different epithelia vary in a small degree only in the 
different cases, therefore can always be diagnosed. Care must be taken 
not to mistake folded epithelia from the upper layers for columnar epi- 
thelia, which they sometimes resemble; they are, however, somewhat 
more irregular, always paler, and more finely granular than those from 
the deepest layer. 

Mucus in the form of threads and corpuscles can be found in almost 



282 URINARY ANALYSIS AND DIAGNOSIS. 

every case, but is more abundant in the severer inflammations. Mucus- 
threads are pale, and consist of fine, sometimes hardly perceptible fibres. 
They should never be mistaken for connective-tissue shreds — which we 
do not expect to find unless the case is intense or hemorrhages occur — 
since they are pale, finely striated, and the individual fibres usually run 
quite parallel. When large, mucus-threads may branch off and some- 
times fill the greater part of the field. Besides the threads, mucus-cor- 
puscles are also found in varying numbers. Such corpuscles are pale, 
more or less irregular in outline, finely granular, and do not contain a 
nucleus. They may have the size of pus-corpuscles, but are often consid- 
erably larger. Even in the milder cases of cystitis the so-called cylin- 
droids or mucus-casts — pale, delicate, striated formations — can also be 
seen. 

The only other features which may be found in these cases are bac- 
teria. Their number has little significance as to the severity of the in- 
flammation, since even in severe inflammations they may be scanty, 
while they may be abundant in a mild case. 

Chronic Catarrhal Cystitis (Fig. 119). — In chronic catarrhal cystitis, 
the reaction of the urine is usually alkaline, and the more chronic the 
case, the more pronounced is this reaction. The sediment generally 
contains the different varieties of phosphates, both complete and incom- 
plete triple, as well as star-shaped simple phosphates. Globules of 
ammonium urate are often quite abundant. 

Pus-corpuscles vary in number according to the intensity of the in- 
flammation, and in many small, glistening fat-granules and -globules will 
be found. Sometimes they contain dark brown granules of pigment. In 
the more intense cases pus-corpuscles are numerous, and are frequently 
swollen, hydropic, or disintegrated. In purely chronic cases red blood- 
corpuscles are scanty or entirely absent. When acute exacerbations or 
hemorrhages ensue, they become considerably more numerous. 

Epithelia are always present in greater or less amount, but their rela- 
tive numbers are somewhat different from those found in acute cystitis. 
While in the latter flat epithelia from the upper layers are quite abundant, 
they are either entirely absent in the chronic cases, or are seen in small 
numbers only; this is one of the differential points of diagnosis. Epi- 
thelia from the upper layers, when present in large numbers, denote either 
an acute case or an acute exacerbation of a chronic inflammation. 
Cuboidal epithelia from the middle layers are always found in varying 
numbers, many containing fat-granules or -globules. Columnar epithelia 
from the deepest layer are seen in the severer cases only, and then in 
small numbers. Free fat-globules are always present. 

Mucus-threads and -corpuscles are constant features in chronic ca- 



»/& ' V e- ■■:■.■■• -c'l ^ • • //// I 




Fig. 119. — Chronic Catarrhal Cystitis (X 500). 
UA, Ammonium urate; TP, triple phosphates; SP, simple phosphates; PC, pus- 
corpuscles ; MB, epithelia from the middle layers of the bladder, containing fat-globules ; 
M T, mucus-threads ; MC, mucus-corpuscles ; BC, bacilli and cocci ; FG, free fat-globules. 



DISEASES OF THE BLADDER. 285 

tarrhal cystitis. In cases having a highly alkaline reaction, the urine is 
ropy and a jelly-like, viscid mass is present, sometimes so pronounced as 
to compose the greater part of the sediment. A urine containing such 
masses always has an ammoniacal odor, and the alkaline salts are ex- 
tremely numerous. Besides the salts and bacteria, such a jelly-like mass 
consists of strings of mucus, sometimes filling entire fields of the micro- 
scope. In many of these cases neither pus-corpuscles nor epithelia can be 
recognized to any great degree, having become hydropic, pale, and ap- 
parently changed to mucus-corpuscles. The appearance of a urine con- 
taining such masses is so characteristic to the naked eye that a diagnosis 
of chronic cystitis can, in many cases, be made without a microscopical 
examination. Bacteria are never absent in chronic inflammations, and 
are usually abundant. 

Subacute Catarrhal Cystitis. — The features found in a subacute 
catarrhal cystitis are a moderate number of red blood-corpuscles, pus- 
corpuscles, as a rule not abundant, a few epithelia from the upper layers 
of the bladder, a moderate number from the middle layers, a few fat- 
globules, and a moderate amount of mucus. The reaction in such cases 
is usually faintly alkaline. 

ULCERATIVE CYSTITIS. 

The development of ulcers in the bladder is not rare, and traumata of 
different kinds are perhaps the most frequent causes. With the presence 
of calculi and parasites in the bladder, but especially in tuberculosis in 
any part of the genito-urinary tract, ulcerative cystitis is of common oc- 
currence. In pronounced cases such a urine has an intensely putrescent 
odor and is very turbid. 

Microscopical Features. — Acute Ulcerative Cystitis (Fig. 120). — Un- 
der the microscope the features of an acute ulcerative cystitis are the 
following: 

The number of pus-corpuscles varies considerably, and they are not 
necessarily abundant. Red blood-corpuscles are always fairly numerous, 
and in many cases even hemorrhages exist. Epithelia from the bladder 
are abundant, and present from all three layers; the columnar epithelia 
from the deepest layer, usually absent in catarrhal inflammation, are 
often almost as abundant as those from the middle layers. 

Connective-tissue shreds are found in large numbers, some of the 
shreds being large, while others are only of small size. These shreds are 
of moderate refraction, and consist of wavy, irregular fibres. The differ- 
ence between them and mucus-threacls, which are also present in varying 
numbers and are much paler than the former, is plain. 

Bacteria are numerous in all these cases, and zoogloea-masses are in- 



286 URINARY ANALYSIS AND DIAGNOSIS. 

variably found. These masses are often large and numerous, and are 
never seen to such an extent in simple catarrhal cystitis. Their diagnosis 
is easy, and when large groups are present around connective-tissue 
shreds, in fresh urine, the existence of an ulcer is almost certain. The 
salts vary considerably in amount in acute cases, and at times they are 
found in small numbers only. 

Chronic Ulcerative Cystitis (Fig. 121). — Alkaline salts, especially 
phosphates, are abundant. Pus-corpuscles are present in moderate num- 
ber, but red blood-corpuscles are usually scanty. Epithelia from the 
upper layers of the bladder are either entirely absent or scanty, though 
transitional epithelia may be found. Cuboidal and columnar epithelia 
are abundant, the latter being often almost as numerous as the former. 
Fat-globules and -granules, both in free groups and in the pus-corpuscles 
and epithelia, are always seen. Connective- tissue shreds are just as abun- 
dant as in acute cases, while mucus-threads and -corpuscles are more 
numerous. Zoogloea-masses are never absent, and may attain large sizes. 
Other bacteria are also found in large numbers. 

When the diagnosis of a chronic ulcerative cystitis has become clear 
from the above features, and when, as not infrequently happens, at- 
tacks of hemorrhage, even if only mild, occur; when, furthermore, no 
evidences of calculi or parasites are found, an examination for tubercle 
bacilli should always be made. In a number of cases, where the clin- 
ical symptoms were vague, but an ulcerative cystitis was present, 
examination for tubercle bacilli revealed the existence of a tuberculosis 
in the urinary tract, and at once cleared up the case. 

In one case, which was examined by the author, the ulcerative cystitis 
was produced by actinomyces. The urine contained a number of small 
granular masses, apparent to the naked eye, and upon examination these 
were found to consist of the characteristic club-shaped conglomerations 
of actinomyces, previously described. 

SUPPURATIVE CYSTITIS. 

Suppurative cystitis is comparatively rare. The diagnosis can be 
made if pus-corpuscles are numerous and epithelia from the different 
layers of the bladder abundant. Connective-tissue shreds are always 
present and red blood-corpuscles quite numerous. In such cases bacteria 
will be seen in larger numbers, but the zooglcea-masses, which are found 
in every case of ulcerative cystitis, are not present, or, if so, not pro- 
nounced. The differential diagnosis between an abscess and an ulcer 
must, however, be made chiefly from the comparative numbers of pus- 
corpuscles, which in an abscess are considerably more abundant. 



UB 




Fig. 120. — Acute Ulcerative Cystitis (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; UB, epithelia from the upper layers of 
the bladder ; MB, epithelia from the middle layers of the bladder ; DB, epithelia from the 
deepest layer of the bladder; CT, connective-tissue shreds; MT, mucus-threads; Z, 
zooglcea-masses ; ZC, connective-tissue shreds with zoogloea-masses ; M, micrococci; 
St, streptococci; B, bacilli. 



MB 



MT 




Fig. 121. — Chronic Ulcerative Cystitis (X 500). 
PC, Pus-corpuscles, some containing fat-globules; MB, epithelia from the middle 
layers of the bladder, some containing fat-globules ; DB, epithelia from the deepest layer 
of the bladder; TP, incomplete triple phosphate; CT , connective- tissue shreds; MT, 
mucus-thread; FG, free fat-globules; Z, zooglcea-mass ; BC, bacilli and cocci; ZC, 
zoogloea-masses with connective-tissue shreds. 



19 



DISEASES OF THE BLADDER. 291 



PERICYSTITIS. 

When an inflammation is present around the bladder, instead of in the 
wall of the bladder proper, and pressure is exerted upon that organ, the 
epithelia from the middle layers of the bladder may show changes in a 
pronounced degree, which have been previously alluded to as endogenous 
new-formations. Such changes will occur when parametritic exudates 
exist, pressing upon the bladder, when a tumor is present either in the 
neighborhood of the bladder or in the wall of the bladder, or even simple 
extravasations of blood in the wall of the bladder may cause them. 
Pressure of any kind, no matter how slight, if continued for some time, 
such a? pressure of the uterus upon the bladder, or of the prostate gland 
on account of hypertrophy of that organ, or inflammations of the seminal 
vesicles, will all produce such changes. 

In simple catarrhal cystitis a small number of epithelia from the mid- 
dle layers may be found, containing a number of nuclei or even newly 
formed pus-corpuscles. So long as these formations are scanty, they may 
be produced by the inflammatory process alone — a fact which has been 
known for many years. As soon, however, as the epithelia become irri- 
tated through pressure of some kind, the endogenous new-formation of 
pus-corpuscles in the desquamated cuboidal or columnar epithelia is very 
abundant. One epithelium may contain from two to four or even six 
such pus-corpuscles, or, instead of them, vacuoles may be seen, or pus- 
corpuscles and vacuoles in varying numbers. 

The features found in a case of pericystitis due to a parametritis are 
shown in Fig. 122. They are the following: 

Pus-corpuscles are present in rather large numbers, and red blood- 
corpuscles are fairly numerous. Cuboidal epithelia from the middle layers 
of the bladder are abundant, and in almost every one the endogenous 
new-formation is plainly visible; smaller cuboidal epithelia from the ure- 
ters are present in moderate numbers, some of which also contain endog- 
enous new-formations. In a few of the pus-corpuscles and epithelia fat- 
globules are seen, and small groups of free fat-globules are also found. 
Mucus-threads are abundant and large, while connective-tissue shreds 
are scanty and small. 

Besides these features, ciliated columnar epithelia from the mucosa of 
the uterus and larger irregular epithelia from the cervix uteri are seen, as 
well as those from the upper and middle layers of the vagina, which, with 
the pus-corpuscles, are sufficient evidences of an endometritis, cervicitis, 
and vaginitis. 



292 URINARY ANALYSIS AND DIAGNOSIS. 



II. TUMORS OF THE BLADDER. 

Although many different varieties of tumors may occur in the bladder, 
the most common, and those which can frequently be diagnosed from an 
examination of the urine, are benign papilloma and malignant sarcoma 
and cancer. Myoma is a rare tumor in the bladder, but when present can 
also be diagnosed, if particles of the tumor appear in the urine. As long 
as no ulceration has taken place, the presence of a tumor of any kind can 
only be suspected; but as soon as ulceration has set in and particles of 
the tumor are found in the urinary sediment, the diagnosis becomes 
positive. 

Clinical Symptoms. — In all tumors of the bladder, benign as well as 
malignant, one of the first, if not the first, and most pronounced symp- 
toms is hematuria, mild in character only at the commencement, and 
occurring at long intervals, but later becoming more pronounced and 
more frequent. This hematuria may take place at any time, and is just 
as common during rest as when the patient is active. Besides the hema- 
turia, pain is present in many cases, but not in all, being more frequent 
in malignant than in benign tumors, and radiating to the perineum, the 
thighs, and the scrotum. In benign growths, pain, if present at all, is 
rarely pronounced. Frequent micturition may exist quite early in the 
disease, and becomes more pronounced in the later stages. 

Malignant tumors sooner or later will cause general symptoms, and, 
as a rule, end fatally in the course of one or two years, although cases of 
undoubted sarcomata have been known to last four or five years. 

None of the symptoms here given are at all characteristic, and micro- 
scopical examination of the urine must be relied upon for a positive diag- 
nosis. Tumors of the bladder may occur at all ages, a case of papilloma 
having been diagnosed by the author from the urine of a child of one year. 

PAPILLOMA. 

Microscopical Features. — The microscopical features in a case of papil- 
loma of the bladder are illustrated in Fig. 123. 

Since hemorrhage is of such common occurrence in these tumors, red 
blood-corpuscles are usually present in the urinary sediment in large 
numbers. These may be irregularly scattered throughout the field, or 
are found conglomerated in groups, partly yellowish, containing haemo- 
globin, but at the time of examination mostly colorless, with the charac- 
teristic double contours. In cases of active hemorrhages, hsematoblasts, 
having the appearance of red blood-corpuscles, but only half their size, 




MT 



CE 
FG 

MC 

-MU 
-RB 

CT 

CE 
MB 



Fig. 122. — Pericystitis, Due to Parametritis (X 500). 
RB, Red blood-corpuscle ; PC, pus-corpuscles ; UB, epithelium from the upper layers 
of the bladder; MB, epithelia from the middle layers of the bladder, with endogenous 
new-formations; UE, epithelia from the ureter, with endogenous new-formations; MU, 
epithelia from the mucosa uteri ; CE, epithelia from the cervix uteri ; UV, epithelia from 
the upper layers of the vagina; MV, epithelia from the middle layers of the vagina; 
MT, mucus-thread ; MC, mucus-cast ; CT, connective-tissue shred ; FG, free fat-globules. 



DISEASES OF THE BLADDER. 295 

may be abundant. If the latter contain haemoglobin, so that the double 
contour is not seen, care must be exercised not to mistake them for fat- 
globules, or even conidia; they may be found in large groups as well as 
singly, between the regular-sized blood-corpuscles. 

The characteristic features of a papilloma are peculiar connective- 
tissue shreds, which, as a rule, are abundant. Although variously sized 
shreds, not differing in any respect from those generally seen in the urine, 
are present, the larger numbers have an entirely different appearance. 
They are long, or extremely irregular, frequently branching in different 
directions, and often assume the shape of coils or knobs. Such shreds are 
coarsely granular, and not infrequently contain a number of inflammatory 
corpuscles. Again, they may be found studded with fat-globules of differ- 
ent sizes, some of these being quite large. In rare cases, blood-vessels, 
either in process of formation or fully formed, some of considerable size, 
may be contained in them. 

The forms in which connective-tissue shreds may be found in the urine 
when a papilloma exists are sometimes so peculiar that a diagnosis can 
only be made when smaller and more regular shreds are found. In one 
case it seemed at first glance as if large parasites of an unknown nature 
were present, but a more careful examination showed large knobs and 
coils, in which capillary blood-vessels, filled with blood-corpuscles, were 
seen coursing in various directions. The individual fibres of such shreds 
may have entirely disappeared, and the whole shred appears as a mass of 
coarsely granular protoplasm; these shreds might well be termed proto- 
plasmic outgrowths of connective tissue. The more common varieties of 
connective-tissue shreds found in papilloma are shown in the illustration. 

In all cases of papilloma, epithelia from the different layers of the blad- 
der, more especially the cuboidal and columnar varieties, are quite abun- 
dant, and usually are more or less studded with fat-globules, which latter 
are also seen in small groups. Many of the bladder epithelia contain the 
endogenous new-formations. Besides these, irregular, coarsely granular 
epithelia, with endogenous new-formations — the covering epithelia of the 
papilloma — are also present. These have the size of bladder epithelia, 
though they are always irregular, and are not characteristic of the papil- 
loma. In none of the cases were the epithelia found adherent to the con- 
nective-tissue shreds, and care must be taken not to attempt a diagnosis 
of a tumor from these epithelia alone. 

In every case of papilloma pus-corpuscles are present. They vary in 
amount with the intensity of the accompanying inflammation, which, 
though never absent, differs in degree in different cases. As a rule, the 
pus-corpuscles are present in moderate numbers and are distinct, but 
sometimes they become massed into pale, irregular degenerated groups, 



296 URINARY ANALYSIS AND DIAGNOSIS. 

which are not easily diagnosed. In rare cases enormous masses of 
fibrin are found in the urine — regular fibrinuria. Mucus-threads are 
always present, though the other features may render them indistinct. 

SARCOMA. 

As has been described in the previous chapter, a sarcoma can be diag- 
nosed from the urine, when present in any part of the genito-urinary 
tract. Sarcomata of the bladder, although not common, undoubtedly 
occur. As in all tumors of the bladder, hemorrhages are frequent in sar- 
coma, and when the urine is examined during an attack of hemorrhage, 
the diagnosis becomes more difficult, since no such characteristic connec- 
tive-tissue shreds as in papilloma are here found. 

Microscopical Features. — If blood-corpuscles are present in moderate 
numbers only at the time of the examination, the other features are dis- 
tinct enough, and groups of small, glistening, frequently homogeneous, 
coarsely granular corpuscles, larger than red blood-corpuscles, but 
smaller than pus-corpuscles, are found in large numbers. These cor- 
puscles, resembling lymph-corpuscles, are the elements characteristic 
of a small round-celled or lympho-sarcoma. Connective-tissue shreds 
must, however, always be seen before the diagnosis becomes positive; 
these shreds may attain large sizes, and frequently contain inflamma- 
tory corpuscles. In most cases they do not differ from the shreds 
commonly found in urine, except by their large size. 

The other features seen in a sarcoma of the bladder are the same as 
those seen in every severe subacute or chronic catarrhal or ulcerative cys- 
titis, epithelia from the deepest layer of the bladder being rarely absent. 
Many epithelia contain endogenous new-formations, and these are not in- 
frequently seen in the accompanying epithelia from the ureters. Pus- 
corpuscles and fat-globules in varying numbers, together with mucus- 
threads, complete the features in these cases. 

CARCINOMA. 

The varieties of cancer developing in the bladder are principally the 
villous, the squamous, and the medullary, the first two being more com- 
mon than the third. Villous or papillary cancer, the so-called cauliflower 
growth, is probably due in many cases to a secondary malignant change 
of a previously benign papilloma. This can be proved in those cases in 
which a tumor, having lasted for years and having always given the char- 
acteristics and features of a benign papilloma, becomes changed and as- 
sumes the features of malignancy. Such a villous cancer is in reality only 



PCT 




Fig. 123. — Hemorrhage from the Bladder, Due to Papilloma 
of Bladder (X 500). 
RB, Red blood-corpuscles; H, haematoblasts; PC, pus-corpuscles; MB, epithelia from 
the middle layers of the bladder, containing fat-globules; DB, epithelia from the deepest 
layer of the bladder; PE, covering epithelia of papilloma; UB, epithelium from the upper 
layers of the bladder; PCT, connective-tissue shreds from papilloma; CT , connective- 
tissue shred; FG, free fat-globules. 



DISEASES OF THE BLADDER 299 

a subvariety of a squamous cancer or epithelioma, but seems to be more 
frequently seen in the bladder than the regular epithelioma. Medullary 
cancer, perhaps the most malignant, that is, most rapidly fatal of all can- 
cers, does not often develop in the bladder, and if it does, can hardly be 
distinguished by an examination of the urine, unless large masses of the 
tumor are cast off. 

Microscopical Features. — The features found in a urinary sediment of 
a case of villous cancer are depicted in Fig. 124. 

At the time this urine was examined, there was no active hemorrhage; 
therefore red blood-corpuscles were not numerous, though some were 
present. In different fields variously sized, dark brown or even black 
blood-clots were seen, composed of masses of disintegrated blood-cor- 
puscles. Hsematoidin crystals, in the form of small plates and needles, 
the latter also seen in small conglomerations, were present, though not 
abundant. 

The connective-tissue shreds found in villous cancer may be even 
larger and more irregular than those seen in papilloma, not infrequently 
having the appearance of cauliflower-like excrescences, or containing 
large bulbs or knobs. These shreds are always coarsely granular and 
filled to a greater or less degree with inflammatory corpuscles, more pro- 
nounced than in papilloma. Again, a number of these shreds contain 
large, irregular cancer epithelia, sometimes even small nests, a feature 
never found in the connective tissue from a papilloma. Capillary blood- 
vessels, filled with blood-corpuscles, are sometimes found in these shreds, 
and may pervade their entire length. 

The original fibrous structure of the connective- tissue shreds has be- 
come changed, and only scanty fibres are present, the shred frequently 
appearing as a mass of coarsely granular protoplasm. Connective-tissue 
masses with a pronounced epithelial covering may perhaps occur in the 
urine in rare cases, but the detached masses from the tumor are usually 
changed, being broken down more or less completely, so that an epithe- 
lial covering is rarely seen. 

Besides the epithelia from the middle and deepest layers of the blad- 
der, containing fat-globules and endogenous new-formations, large num- 
bers of irregular, coarsely granular epithelia, partly single, partly in 
groups, are present; these also contain fat-globules and endogenous new- 
formations, and are the cancer epithelia. As long as these epithelia are 
seen alone, without other evidences of cancer, no diagnosis of a malignant 
tumor can be made, since they cannot be differentiated from other epi- 
thelia, as, for instance, those found in papilloma. In pronounced cases 
of cancer, however, variously sized epithelial nests may be seen, contain- 
ing three, four, or more cancer epithelia, and as soon as these are found 



300 URINARY ANALYSIS AND DIAGNOSIS. 

the diagnosis of a cancer becomes positive, even though the connective- 
tissue shreds should not be as characteristic as above described. Pus- 
corpuscles are always present in moderate or large numbers. 

Not only can a villous cancer be diagnosed, as just described, but also 
a regular epithelioma. In such cases the urine may contain epithelial 
masses showing a pronounced concentric arrangement, and even 
different degenerations of the epithelia, especially cornification, pro- 
ducing shining, irregular masses — the so-called cancer pearls — may be 
present. All the other features remain the same. 

The positive diagnosis of medullary cancer from the examination of 
urine is difficult, though the presence of a cancer of some kind can, as 
a rule, be made from features similar to those described. 

When a tumor in the bladder has existed for some time, secondary 
inflammations of the ureter, the pelves of the kidneys, and the kidneys 
frequently develop sooner or later, and may become pronounced. In the 
kidney both interstitial or catarrhal and parenchymatous or croupous 
inflammation may appear. The urine then shows all the features of 
such an inflammation, in addition to those of the tumor. In the case of 
a child one year of age, in which a papilloma of the bladder existed, all 
the features of a subacute croupous nephritis were also found, and the 
case proved fatal in a short time. 



III. PARASITES IN THE BLADDER. 

That a large number of micro-organisms of different kinds may not 
infrequently be found in the bladder, has already been mentioned. 
Symptoms of a more or less pronounced cystitis will sooner or later ap- 
pear in almost all those cases. 

Animal parasites are also occasionally found in the bladder, among 
these being echinococci, actinomyces, distonia hcematobium, and filaria san- 
guinis, as well as ascaris lumbricoides , strovgylus gigas, and oxyuris ver- 
micularis. The diagnosis of these parasites is possible only when either 
their ova or the parasites themselves can be discovered in the urine. 
Many of these will invade the bladder only secondarily, being present in 
other organs, as the kidney or pelvis, or find their way into the bladder 
through the urethra. 

In every case of this kind, either hemorrhage or inflammations of 
var}dng degrees of intensity will sooner or later develop, with all the char- 
acteristic features in the urine. Ulcers are often due to such parasites, 
as, for instance, in the case of actinomycosis of the bladder previously 
mentioned. 




Fig. 124. — Villous Cancer of the Bladder (X 500). 
RB, Red blood-corpuscles; PC, pus-corpuscles; UB, epithelia from the upper layers of 
the bladder; MB, epithelia from the middle layers of the bladder, containing fat-globules 
and endogenous new-formations; DB, epithelia from the deepest layer of the bladder; 
CE, cancer epithelia; CN, cancer nests; CT, connective-tissue shreds; H, hsematoidin 
crystals; BC, blood-clot; FG, free fat-globules. 



CHAPTER XVIII. 

DISEASES OF THE SEXUAL ORGANS. 

Diagnosis of diseases of the sexual organs by microscopical examina- 
tion of the urine must of necessity be limited; it is not of so great prac- 
tical importance as in diseases of the urinary organs, since the clinical 
symptoms are in many cases sufficiently clear. There are, however, cases 
where the examination of the urine will either corroborate a suspected 
diagnosis or may even lead to the clearing up of the case when the clinical 
symptoms are not plain. This will naturally be of more common occur- 
rence in diseases of the male than of the female tract, in which latter, 
examination of the patient is, as a rule, sufficient for the diagnosis. 

In the male, inflammations of the urethra, the prostate gland, and the 
seminal vesicles can be diagnosed from urine examination, while in the 
female those of the vagina are easily diagnosed, and sometimes also those 
of the cervix of the uterus and the uterine mucosa. 

URETHRITIS 

Acute Urethritis. — The clinical symptoms of an acute urethritis, 
whether gonorrhceal or non-gonorrhceal, are so evident that an examina- 
tion of the urine is never required to clear up the case. When the urine 
is examined for other purposes at the time such a urethritis is present, 
large numbers of urethral epithelia are always found. In the first days of 
a urethritis the irregular, flat epithelia from the upper layers are more 
abundant, but soon the cuboidal and columnar epithelia are seen. Pus- 
corpuscles are present to a varying degree in every case. 

Chronic Urethritis. — The symptoms of a chronic urethritis, espe- 
cially when of a mild character, may be so slight that an examination of 
the urine will help to clear up the diagnosis. 

In many or these cases conglomerations of mucus with pus-corpuscles 
and epithelia — the so-called gleet-threads — are found, even though they 
are scanty. Under the microscope these threads (Fig. 57) consist of a 
varying amount of mucus, both fibres and corpuscles, from the mucous 
glands of the urethra; pus-corpuscles, which are abundant in the more 
pronounced, but may be quite scanty in the mild cases, and urethral epi- 

303 



304 URINARY ANALYSIS AND DIAGNOSIS. 

thelia, which also vary in number. Besides these features, epithelia from 
the prostate gland are almost invariably present, and are usually more 
numerous than the urethral, which latter may at times not be found at 
all. The larger numbers of pus-corpuscles and epithelia are seen studded 
with small fat-globules, and these may also be seen upon and between 
the mucus- threads. If gleet- threads are not present, irregular urethral 
epithelia in small numbers, with pus-corpusles, mucus-strings, and 
prostatic epithelia, are seen in many cases of chronic urethritis. 

When an ulceration or stricture exists in the urethra, the urine, as a 
rule, shows some features. In an ulceration, red blood-corpuscles in at 
least moderate numbers, pus-corpuscles, bacteria — especially the zooglcea- 
masses — urethral epithelia, mostly the cuboidal and columnar varieties 
together, and connective-tissue shreds are never absent. As the prostate 
gland almost invariably becomes involved in these cases, prostatic epithe- 
lia are also present. 

In stricture of a mild character, small connective-tissue shreds, with 
a few epithelia from the urethra and prostate gland, and a few pus-cor- 
puscles, are not infrequently seen, although there may be no features 
whatever in the urine of such cases. The urethral epithelia may have two 
or even more nuclei. 

PROSTATITIS. 

The diagnosis of a prostatitis from the urine is undoubtedly of greater 
importance than that of a urethritis, since, especially in the mild chronic 
cases, the clinical symptoms may not be sufficiently pronounced. 

Causes. — The causes of a prostatitis are numerous, though probably 
the most frequent cause of an acute inflammation is an acute urethritis. 
The passage of unclean instruments, such as sounds or catheters, injec- 
tions of chemical agents, or any irritant or injury of whatever kind, such 
as may be due to horseback or bicycle riding, may cause a prostatitis, as 
well as simple exposure to cold and wet. In the course of febrile diseases 
it also develops occasionally. 

Chronic prostatitis may be produced by stricture of the urethra, mas- 
turbation, excesses in venery, hemorrhoids, constipation, or by inflamma- 
tions of the neighboring organs. 

Clinical Symptoms. — An acute prostatitis, if severe, may be ushered 
in by chills and fever, followed by discomfort or pain in the perineal re- 
gion and frequent micturition. The pain is usually increased upon mo- 
tion, and the perineum is found to be sensitive upon pressure. 

In chronic prostatitis the symptoms may be slight, the principal one 
perhaps being the occasional discharge of a small amount of a clear, viscid 
fluid, constituting the so-called prostatorrhoea; this flow is usually in- 



DISEASES OF THE SEXUAL ORGANS. 305 

creased upon defecation. Besides this, slight discomfort and tenderness 
in the perineum, frequent micturition, and slight pain at the end of urina- 
tion may be present. Enlargement of the gland may cause more or less 
retention of urine. 

Features Found in Urine. — The appearance of the urine varies con- 
siderably with the intensity of the inflammation, and is not characteris- 
tic. In acute cases slight or more pronounced hemorrhages may take 
place, and cause the urine to assume a darker color ; when considerable pus 
is present it will be more or less turbid, and also contain a varying amount 
of albumin. In mild chronic cases the urine may be perfectly clear. 

When such a urine is examined for albumin, it must not be forgotten 
that whenever pus-corpuscles and red blood-corpuscles are present albu- 
min will always be found, its amount depending upon the amount of pus 
and blood, so that in cases of abscesses or hemorrhages the urine may con- 
tain considerable albumin, and faint traces are rarely absent when there 
is any inflammation of the prostate gland. It is evident, therefore, how 
important a microscopical examination of the urine becomes in all these 
cases, since such an examination alone will determine whether the kid- 
neys are inflamed, and this be the source of albumin, or whether the albu- 
min is due simply to the prostatitis. 

Acute Prostatitis. — In an acute prostatitis of moderate severity, the 
features found in the urinary sediment are red blood-corpuscles in vary- 
ing numbers, pus-corpuscles, mucus, and epithelia from the prostate 
gland. Red blood-corpuscles are never absent in an acute inflammation, 
and are numerous when hemorrhages occur, as is sometimes the case. 
Pus-corpuscles vary in number according to the degree of intensity of the 
inflammation. Mucus, in the form of threads and corpuscles, is always 
increased, and may be present in large amount. 

The characteristic features of a prostatitis are the epithelia. The 
prostate gland is, as a rule, lined by simple cuboidal epithelium, though 
occasionally a pseudo-stratified epithelium, partly cuboidal and partly 
columnar, is seen; while the ducts of the gland are lined by columnar 
epithelia. The cuboidal epithelia are about twice the diameter of the pus- 
corpuscles, and are larger than those from the convoluted tubules of the 
kidney. They have the same size as the cuboidal epithelia from the ure- 
ters, and when they are present alone, without the columnar epithelia 
from the ducts, the comparative number of these, with those of the kid- 
ney and pelvis of the kidney, must be taken into consideration. An in- 
flammation of the ureters is almost invariably secondary to a nephritis 
or pyelitis, and when the epithelia from the kidney or pelvis, or both, are 
seen, together with a small number of those twice the size of the pus- 
corpuscles, they are always ureteral. The absence of symptoms of a 



306 VRINAEY ANALYSIS AND DIAGNOSIS. 

pyelo-nephritis, but the presence of a varying number of cuboidal epi- 
thelia double the size of pus-corpuscles, would show that they are from 
the prostate gland. Since a prostatitis, especially when it has lasted for 
some time, may cause a secondary inflammation of the bladder, the ure- 
ters, pelvis of the kidney, and kidney, epithelia from all these organs may 
be present, and here not only the comparative number, but also the clin- 
ical symptoms of the case, will have to be taken into consideration to 
determine the positive source of the epithelia. 

On the other hand, in an inflammation of the prostate gland the col- 
umnar epithelia from the ducts of the gland are almost invariably pres- 
ent with the cuboidal epithelia in moderate or even large numbers, while 
the columnar epithelia from the ureters are rarely seen, and then in small 
numbers only. The columnar epithelia from the pelvis of the kidney, 
although they var}^ in size to a certain degree, are always somewhat larger 
than those from the ducts of the prostate gland and more irregular, so 
they cannot be mistaken for the latter. 

A prostatitis is in most cases associated with inflammation either of 
the urethra or of the bladder (especially the neck), or both, and the epi- 
thelia from these organs will then be associated with those from the pros- 
tate gland. Severe cases, as already mentioned, are ascending in charac- 
ter, producing a pyelitis and finally a nephritis, with all the accompanying 
features of the same. 

Acute suppurative prostatitis, or abscess of the prostate gland, is of 
common occurrence, and its features are illustrated in Fig. 125. 

We see here red blood-corpuscles in moderate numbers, and pus-cor- 
puscles in extremely large amount, which not infrequently fill up entire 
fields of the microscope. Cuboidal epithelia from the prostate gland, as 
well as columnar epithelia from the ducts, are always present in these 
cases, and are not infrequently found in groups. Connective- tissue shreds 
are seen in varying numbers, and unless they are found the diagnosis of 
an abscess must never be made, even if pus-corpuscles and epithelia are 
numerous. The latter is the chief point of distinction between a severe, 
r^ut non-suppurative, prostatitis and an acute abscess. Mucus-threads 
may be found in large numbers. 

When a suppurative prostatitis is the result of a urethritis, which is 
frequently the case, the irregular epithelia from the urethra will be found 
accompanying the features just described, and, as a rule, epithelia from 
the upper and middle layers of the bladder are also present, showing a 
cystitis. In both the urethral epithelia and the bladder epithelia an en- 
dogenous new-formation of pus-corpuscles may be seen. 

Chronic Prostatitis. — Chronic prostatitis will give characteristic feat- 
ures under the microscope (Fig. 126). 




Fig. 125. — Acute Abscess of the Prostate Gland (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles ; PE, epithelia from the prostate gland ; 
DP, epithelia from the ducts of the prostate gland; UE, epithelia from the urethra; 
CT, connective-tissue shreds; MT, mucus-threads; MB, epithelia from the middle layers 
of the bladder. 




Fig. 126. — Chronic Prostatitis (X 500.) 
PC, Pus-corpuscles containing fat-globules; PE, epithelia from the prostate gland, 
containing fat-globules; DP, epithelia from the ducts of the prostate gland, containing 
fat-globules; MB, epithelia from the middle layers of the bladder; NB, epithelia from the 
neck of the bladder; MT, mucus-threads; FG, free fat-globules. 



DISEASES OF THE SEXUAL OBGANS. 311 

Red blood-corpuscles are here either entirely absent or scanty, and 
pus-corpuscles are present in moderate numbers only. Cuboidal as well 
as columnar epithelia from the prostate gland and its ducts are quite abun- 
dant, the former being often found in groups of four, five, or more. Both 
the pus-corpuscles and the epithelia are studded with glistening fat-glob- 
ules and -granules, which latter also lie free. In the case from which the 
illustration was drawn, this fatty change was extremely pronounced — 
more so than is usually the case. Every epithelium and almost every 
pus-corpuscle were filled with these globules, giving the whole corpuscle 
a glistening appearance. The free groups of fat-globules were numerous 
and large, the individual globules in many groups being of considerable 
size. Mucus-threads were seen in moderate numbers, but connective- 
tissue shreds were absent. 

In this case no urethral epithelia were seen, but the accompanying 
cystitis was pronounced, so that the epithelia from the bladder were quite 
abundant. Not only the regular cuboidal epithelia from the middle layers 
of the bladder, studded with fat-globules, were present, but also larger 
epithelia from the neck of the bladder. Mention should here be made of 
the fact that the epithelia from the neck of the bladder are usually larger 
than those found in the other portions of the bladder, and may even at- 
tain the size of vaginal epithelia. These large epithelia are, however, 
never numerous, are seen only with the other features, and are not studded 
with bacteria, as is almost invariably the case in the epithelia from the 
upper layers of the vagina. 

Hypertrophy of the prostate gland may give characteristic features in 
the urine, even before the clinical symptoms are sufficiently pronounced 
to lead to a suspicion of the affection (Fig. 127). In all these cases the 
features of a chronic prostatitis are found, usually with a small or moder- 
ate number of pus-corpuscles only, but with small connective-tissue 
shreds, which in many cases are scanty. If the latter are seen with all the 
evidences of a chronic prostatitis, especially when the age of the patient 
is above forty or forty-five years, the diagnosis of hypertrophy can be 
made. When the hypertrophy becomes more pronounced, endogenous 
new-formations will be seen in the larger numbers of epithelia from the 
middle layers of the bladder, as well as in those from the urethra and even 
in a number from the prostate gland and ducts. In these cases prostatic 
concretions, previously described, are not rarely found. 

Tuberculosis. — Tuberculosis of the prostate gland is probably never 
present alone without an involvement of the neighboring organs, and is a 
comparatively rare affection. It will always give the symptoms of a pros- 
tatitis or an abscess of the prostate gland with a varying number of pus- 
corpuscles, and not infrequently even connective-tissue shreds. When 



312 UEINAEY ANALYSIS AND DIAGNOSIS. 

it is suspected, repeated examinations for tubercle bacilli must be 
made. 

Tumors. — Tumors of the prostate gland are not of rare occurrence, 
and both sarcoma and cancer are met with, and can be diagnosed from 
the urine. In sarcoma, the characteristic small, glistening bodies previ- 
ously described, with large connective-tissue shreds, and the evidences of 
a chronic prostatitis are seen; while in cancer the connective-tissue shreds 
and epithelia, described in cancer of the bladder, may be found in the 
urine. The clinical symptoms must of necessity help the microscopical 
examination in many of these cases. In some cases neither sarcoma cor- 
puscles nor cancer epithelia can be found, but all the evidences of a pro- 
nounced hypertrophy of the prostate are seen in urine, together with 
large connective-tissue shreds, which of themselves are sufficient cause of 
suspicion of the presence of a tumor. 

SPERMATORRHOEA. 

Spermatorrhoea, which in young men is by no means rare, and con- 
sists in an occasional involuntary flow of semen, especially at the end of 
defecation, or even upon urination, cannot infrequently be diagnosed 
from the urine. 

When a urine is to be examined to prove the presence of a spermator- 
rhoea, it is best to take either the first urine voided in the morning or the 
last quantity voided during defecation. In such a urine the elements of 
the sperma, with spermatozoa in large numbers, will be found. In almost 
all these cases a prostatitis of varying degrees of intensity will exist and 
give the features under the microscope. 

Whenever a prostatitis is found in young men in whom no other cause 
can be discovered, a suspicion of spermatorrhoea must arise, even when 
no spermatozoa are seen in the urine first examined. Repeated examina- 
tions will invariably show these, and render the diagnosis positive. The 
clinical symptoms of a chronic prostatitis — that is, an occasional discharge 
of a clear, viscid fluid, especially in younger men — may not infrequently 
lead to the mistaken diagnosis of spermatorrhoea, which disease must 
never be diagnosed without the evidence of a discharge of sperma. 

Besides the prostatic epithelia, those from the seminal vesicles and 
ejaculatory ducts may also be seen in the urine. Mucus is always present 
in these cases in large amount, and mucus-casts or cylindroids may be 
abundant. Care must be taken not to mistake these for true hyaline 
casts from the uriniferous tubules of the kidney, which they sometimes 
resemble to a marked degree ; sharp focusing will always bring out the 
pale fibres of mucus, thus proving that they are not hyaline casts. 



-MT 



UJS 




Fig. 127. — Chronic Prostatitis, with Hypertrophy of the Prostate Gland 

(X 500). 

RB, Red blood-corpuscles ; PC, pus-corpuscles containing fat-globules ; PE, epithelia 
from the prostate gland, some with endogenous new-formations; PD, epithelia from the 
ducts of the prostate gland ; UE, epithelia from the urethra with endogenous new-forma- 
tions and fat-globules ; MB, epithelia from the middle layers of the bladder with endog- 
enous new-formations; NB, epithelia from the neck of the bladder; CT, connective- 
tissue shreds; MT, mucus-threads; MC, mucus-cast; FG, free fat-globules. 



DISEASES OF THE SEXUAL ORGANS. 315 



SEMINAL VESICULITIS. 

Seminal vesiculitis, or spermatocystitis, has received considerable at- 
tention of late years by many authors, who all agree that the affection is 
of much more common occurrence than has been supposed. Although 
frequently of gonorrheal origin, this is not the exclusive cause of the dis- 
ease, and Fuller claims that in about one-third of the cases it is tubercular 
in character. It may also be catarrhal in origin, though most authors be- 
lieve that the non-gonorrhoeal cases are rare. 

Clinical Symptoms. — The symptoms of a spermatocystitis are not al- 
ways well pronounced, and, therefore, may escape detection for years. 
Disturbances of the sexual functions are most constant, though they vary 
in different cases. In many there is a marked increase of sexual desire, 
but no relief is afforded by the coitus. This is, however, not present in 
every case, and in some there is a diminution or even absence of the de- 
sire. Pain may be present in the perineum and upon urination, and there 
may even be tenesmus. In many cases an intermittent or even constant 
discharge from the urethra, which is sometimes quite profuse, is present, 
and some patients will complain of bloody emissions. 

It will be seen that neither one of these symptoms is at all character- 
istic, and rectal examination must be resorted to. This is sometimes suc- 
cessful, but in many cases is not; when the seminal vesicles can be reached, 
they will be found distended and tender to the touch. A positive diagno- 
sis can be reached only by a microscopical examination, and the seminal 
fluid will, in all these cases, contain pus-corpuscles, and usually, especially 
in acute cases, red blood-corpuscles. 

Features Found in Urine. — The microscopical examination of the 
urine will often clear up the case. When the early morning urine, espe- 
cially the part first voided, or the last urine passed at defecation, is exam- 
ined, spermatozoa are often found. The features seen in the first morning 
urine in a case of chronic seminal vesiculitis are illustrated in Fig. 128. 

Spermatozoa are here found in large numbers. Some of them have 
the normal appearance, but others appear changed. The change takes 
place in the head of the spermatozoon, which becomes larger, round, and 
granular, and finally may resemble a pus-corpuscle, so that we seem to 
see pus-corpuscles with tails in such a urine. This change is characteristic 
of the disease, and is frequently seen, though not always in a pronounced 
degree. The originally oval head first becomes rounded and then some- 
what enlarged and granular. In milder cases no further enlargement 
takes place, while in the more intense cases a number assume the size of 
pus-corpuscles, being either coarsely or finely granular. Such a diagnosis 



316 URINARY ANALYSIS AND DIAGNOSIS. 

of changed spermatozoa should be made only when they are distinct and 
unbroken, their heads and tails being intact. Broken and distorted heads 
of spermatozoa, also seen in chronic seminal vesiculitis, are useless for a 
diagnosis, since they may become broken in urine under normal condi- 
tions. 

Besides the spermatozoa, pus-corpuscles are always found in such a 
urine, and may be either scanty or numerous, according to the degree of 
inflammation. Since suppuration not infrequently occurs in the seminal 
vesicle, pus-corpuscles may be very numerous. Red blood-corpuscles are 
almost always present, though their number also varies considerably, 
being abundant in the more pronounced and scanty in the milder or the 
chronic cases. 

Epithelia from the seminal vesicles and ejaculatory ducts can always 
be found. The former are small, irregular, non-ciliated; the latter are 
originally columnar ciliated epithelia, in some of which the cilia will be 
seen, while in others they are broken off. When they are broken, delicate 
parallel rods in the interior of the epithelia, near their basal surfaces, may 
indicate that the epithelia were originally ciliated. 

In all cases examined, epithelia from the prostate gland were present, 
showing that the prostate gland was also inflamed. The numbers of pros- 
tatic epithelia will, however, vary considerably, though they are usually 
fairly abundant, both the cuboidal and columnar epithelia being seen. In 
the more chronic cases fat-globules are found, both in the epithelia and 
lying free. Mucus is always greatly increased in these cases, and cylin- 
droids or mucus-casts may be numerous; the mucus- threads sometimes 
assume large sizes. When suppuration exists, connective-tissue shreds 
are always present. Epithelia from the urethra and the bladder may 
accompany the other features. 

Hemorrhage from the Seminal Vesicles. — Hemorrhages from the 
seminal vesicles are not rare, and may be due to traumatism of any kind, 
as well as to tuberculosis and gonorrhoea. Such a hemorrhage may be 
primarily caused by excesses in venery, as in the case depicted in Fig. 129, 
in which it immediately followed excessive sexual indulgence in a previ- 
ously strong, healthy man, continued for some time, and was followed by 
an inflammation of the vesicles and prostate gland. 

When this urine was examined under the microscope, all the evidences 
of an active hemorrhage were present: red blood-corpuscles, partly cre- 
nated and partly lying edgewise, being abundant, and small haemato- 
blasts also being found in moderate numbers; besides these, strings of 
fibrin were seen in different fields. Small, irregular, columnar epithelia 
from the seminal vesicles, some of which contained pigment granules, 
were present in small to moderate numbers, and a few longer, slender, 




Fig. 128. — Chronic Sperm atocystitis, or Seminal Vesiculitis (X 500). 

RB, Red blood-corpuscle ; PC, pus-corpuscles; NS, normal spermatozoa; ES, sperma- 
tozoa with enlarged and granular heads; SV, epithelia from the seminal vesicles; ED, 
epithelium from the ejaculatory ducts; PE, epithelia from the prostate gland; PD, epi- 
thelia from the ducts of the prostate gland; MT, mucus-thread; MC, mucus-cast; FG, 
free fat-globules. 




Fig. 129. — Hemorrhage from Seminal Vesicles, with Acute Prostatitis 

(X 500). 

RB, Red blood-corpuscles ; H, Haematoblasts ; WC, white blood-corpuscles ; PC, pus- 
corpuscles; SV, epithelia from the seminal vesicles; ED, epithelia from the ejaculatory 
ducts; PE, epithelia from the prostate gland; PD, epithelium from the ducts of the 
prostate gland; F, strings of fibrin; CT, connective-tissue shred; MT. mucus-thread. 



DISEASES OF THE SEXUAL ORGANS 321 

partly ciliated epithelia from the ejaculatory ducts were also found. Be- 
sides these features, the specimen contained pus-corpuscles, connective- 
tissue shreds, mucus-threads, and cuboidal and columnar epithelia from 
the prostate gland and its ducts, showing a prostatitis. 

In an active hemorrhage of this kind, white blood-corpuscles or leuco- 
cytes are invariably present. These cannot be differentiated from pus- 
corpuscles, and, as long as they are seen in small numbers only, the pres- 
ence of the latter must not be diagnosed. As soon as these corpuscles are 
found in moderate numbers, some are undoubtedly pus-corpuscles, and 
the existence of an inflammation besides the hemorrhage then becomes 
plain. 

VAGINITIS. 

Inflammations of the vagina, especially mild chronic cases, are of 
common occurrence and have little significance, the only symptom being 
a slight discharge; few women who have borne children are entirely free 
from this affection. The severer cases may be due to many causes, such 
as exposure to cold, gonorrhceal infection, or injuries of any kind, or may 
be secondary to an inflammation of the uterus. 

Features Found in Urine. — It is rare that in the urine of a female vag- 
inal epithelia are not found in greater or less amount. Epithelia from 
the upper layers are shed in a small amount in perfect health, and have 
no significance; such epithelia may be seen even in small children. So 
long as the flat epithelia from the upper layers are present alone in small 
numbers, without cuboidal epithelia from the middle layers and without 
pus- corpuscles, the diagnosis of a vaginitis cannot be made. As soon, 
however, as large cuboidal epithelia are also present, a pathological proc- 
ess of some kind exists in the vagina. 

Catarrhal Vaginitis. — The common forms of vaginitis seen in the 
urine are the mild chronic cases, and the features found are shown in Fig. 
130. 

Pus-corpuscles are always present, but usually in small numbers only. 
Epithelia from the upper and middle layers of the vagina are quite nu- 
merous. These epithelia are considerably larger than those from the blad- 
der, the upper layers being flat, the middle cuboidal. Epithelia from the 
upper layers are frequently studded with bacilli and cocci, and often con- 
tain variously sized extraneous fat-globules. They may be found in 
groups, which may fill the greater part of the field. Cuboidal epithelia 
from the middle layers, which in urine usually appear round or oval. 
though they vary in size sometimes to a great degree, are always larger 
than those from the bladder, and may also be found in groups. Colum- 



322 URINARY ANALYSIS AND DIAGNOSIS. 

nar epithelia from the deepest layer are not seen in these milder cases, 
but only in severe inflammations or ulcerations. 

Besides these epithelia, small cuboidal epithelia, twice the size of pus- 
corpuscles and exactly similar to those from the prostate gland in the 
male, are usually present; these are the epithelia from the Bartholinian 
gland and denote a slight Bartholinitis. 

Pus-corpuscles, as well as the different epithelia, contain small fat- 
globules in varying numbers in all chronic cases. Free fat-globules may 
also be seen. In most, if not in all cases of vaginitis, micro-organisms, 
both cocci and bacilli, are found, and are, as a rule, quite abundant. 
Their presence has no significance, as it is well known that micro-organ- 
isms always exist in the vagina, the more pronounced if an inflammation 
has developed. The characteristics here described are usually seen in 
urines examined for other reasons and containing other features. 

In acute vaginitis red blood-corpuscles as well as pus-corpuscles will 
be abundant, and vaginal epithelia from the different layers quite numer- 
ous. In simple catarrhal vaginitis the flat and cuboidal epithelia are usu- 
ally present alone, while in vaginitis due to gonorrhoea, and especially in 
ulcerative vaginitis, columnar epithelia from the deepest layer are also 
found, and connective-tissue shreds are present in varying amount. 

Ulcerative Vaginitis. — The features of ulcerative vaginitis, as seen 
in urine, are shown in Fig. 131. Flat epithelia from the upper layers, 
cuboidal epithelia from the middle layers, and columnar epithelia from 
the deepest layer of the vagina are here seen in moderate numbers, while 
pus-corpuscles and red blood-corpuscles are fairly numerous. Connec- 
tive-tissue shreds of varying sizes are present, and some of these are sur- 
rounded by micro-organisms in the form of zoogloea-masses. Mucus- 
strings and cylindroids, the latter at times difficult of differentiation from 
hyaline casts, are also seen, while different micro-organisms, both micro- 
cocci and bacilli, are scattered throughout the specimen. Epithelia from 
the Bartholinian gland may be quite abundant. 

Besides catarrhal and ulcerative vaginitis, traumatic vaginitis due to 
masturbation may be diagnosed from urine. Here pus-corpuscles are 
present in small numbers only, and red blood-corpuscles are not numer- 
ous; but epithelia from all the layers of the vagina are abundant, the 
cuboidal from the middle layers and the columnar from the deepest layer 
being well marked. Epithelia from the Bartholinian gland are also seen 
in moderate numbers. Epidermal scales, showing corrugated edges, 
studded with fat-globules and dirt particles, and faintly granular, if at 
all, are seen in every field. These are derived from the clitoris and 
nymphae. Connective-tissue shreds are also seen, though they are not 
numerous. Micro-organisms and a few fat-globules complete the features. 



MV 




MV 



Fig. 130. — Chronic Catarrhal Vaginitis (X 500). 
PC, Pus-corpuscles containing fat-globules; UV, epithelia from the upper layers of the 
vagina; MV, epithelia from the middle layers of the vagina, containing fat-globules; 
BG, epithelia from the Bartholinian gland; FG, free fat-globules; B, bacilli; M, micro- 




Fig. 131. — Ulcerative Vaginitis (X 500). 
RB, Red blood-corpuscles ; PC, pus-corpuscles; UV, epithelia from the upper layers 
of the vagina; MV ' , epithelia from the middle layers of the vagina; DV , epithelia from 
the deepest layer of the vagina; BG, epithelia from the Bartholinian gland; CT, con- 
nective-tissue shred; ZC, zooglcea-masses surrounding connective-tissue shreds; MT, 
mucus-thread ; MC, mucus-cast ; Z, zodglcea-mass ; M, scattered micrococci ; St, Strepto- 
cocci pyogenes; B, bacilli. 



DISEASES OF THE SEXUAL ORGANS. 327 

Whenever epithelia from the deepest layer and connective-tissue 
shreds are present, we have all the evidences of a destructive process. 
Continuous irritation or injury to the parts by masturbation is sufficient 
to produce these features in small numbers. If an ulcer exists, the pus- 
corpuscles and epithelia are more numerous ; and if traumatism results in 
hemorrhage, red blood-corpuscles are more abundant. The features here 
described may be found accidentally when a urine is examined for other 
pathological conditions, and when seen in that of young girls should al- 
ways lead to a suspicion of masturbation. The cause of a nervous irri- 
tability or neurasthenia is thus not rarely cleared up. 

CERVICITIS AND ENDOMETRITIS. 

Cervicitis and endometritis may also be diagnosed from the urine, 
when the different epithelia from the cervix and mucosa of the uterus are 
present. Epithelia from the cervix uteri are quite large and irregular, 
while those from the mucosa uteri are columnar ciliated. Both are shown 
in Fig. 122. The other features of such an inflammation are similar to 
those seen in any inflammation. In ulcerations or injuries shreds of 
connective tissue are found. In endometritis we occasionally see pus- 
corpuscles with cilia from the mucosa uteri, together with the ciliated 
epithelia. 

Tumors from the uterus can be diagnosed from examination of the 
urine in rare cases only, when a small particle of the tumor is cast off and 
found in the urine. The features of the tumor are similar to those previ- 
ously described, and the character of the epithelia will determine the seat 
of the tumor. 



CHAPTER XIX. 

DETERMINATION OF THE FUNCTIONAL EFFICIENCY 

OF THE KIDNEYS. 

By 

Walter T. Dannkeutheb, M.D., F.A.C.S. 

ASSISTANT PROFESSOR OF GYNECOLOGY, XE^SV YORK POST-GRADU ATE MEDICAL SCHOOL AND HOSPITAL. 

With a view of determining the functional efficiency of one or both 
kidneys, and often of estimating the functional capabilities of the 
patient as well, various methods have been described, which at times 
may be valuable as aids to the chemical and microscopical examination 
of the urine. Many of these renal function tests have proved ex- 
tremely useful to the clinician, and although their scientific exactness 
is open to question, extensive experience has demonstrated that quite 
definite conclusions may be drawn from their proper interpretation. 
A knowledge of the excretory function of the kidneys, as well as the 
stability of renal sufficiency, is frequently of importance, not only for 
the diagnosis, but also for the prognosis, and these tests aid materially 
in obtaining such information. It is imprudent to rely exclusively 
upon the results of one or more function tests, since they constitute 
but part of the evidence. Other clinical data, such as the history, 
physical findings, urine and cystoscopic examinations, and radio- 
graphy, with its various attributes, must be corroborative and con- 
firmative. A discrepancy in the results of two or more function tests 
in the same case may be explained by the fact that different areas of 
the kidneys may be concerned in each instance. One must also bear 
in mind that lost or deranged function may be either temporary or 
permanent, and the reading at any one time may not represent the 
kidney's actual functional ability. Nevertheless, the behavior of the 
function test is always strongly suggestive. 

Renal function tests are serviceable to the medical practitioner by 
furnishing him a better conception of his patient's general metabolic 
activities, especially elimination by the kidneys. They likewise in- 
dicate the progress as well as the extent of involvement or destruction 
of kidney tissue in nephritis, cardio-vascular diseases, and other dis- 
ease processes. To the surgeon they are invaluable, because he may 
determine thereby with certainty the presence of a healthy kidney on 
the opposite side before nephrectomy. They also help in the diagno- 

329 



330 URINARY ANALYSIS AND DIAGNOSIS. 

sis of such surgical conditions as urogenital tuberculosis, ureteral 
stricture, calculus, pyonephrosis, hydronephrosis, etc. There is no 
other diagnostic procedure which demonstrates a compensatory hyper- 
activity to the same degree of accuracy. In the so-called " medical 
nephritis" the excretory inefficiency of the kidneys is generally pro- 
duced by actual disease of some of their histologic structures, or cir- 
culatory alterations, while in " surgical lesions" the impairment of 
function is usually an end-result of the vicious circle of obstructed 
drainage, urinary stasis, back-pressure, infection and epithelial dis- 
integration. 

As has been shown in the preceding chapters, one of the best 
methods of determining the integrity of the kidneys themselves is 
by careful chemical and microscopical examination of the urine. But 
the collection of separate urines from each kidney entails the use of a 
catheterizing cystoscope or one of the segregators, and as these in- 
struments are not always available, such examinations are sometimes 
impossible. When practicable, the specimens should be collected 
simultaneously and for the same period of time and then carefully 
examined, and in many cases the condition of each kidney can thus 
be ascertained. Not only will the character of the pathological pro- 
cess become plain, but also the extent of the lesion, as well as the con- 
stitution of the patient at the time of the examination, thus showing 
whether or not his organism will be able to withstand proposed sur- 
gical procedures. 

Of the special methods which are used for the determination of 
renal function, the phenolsulphonephthalein, indigo-carmine, and 
phloridzin are the most popular and have proven of greatest value. 
The selected agent is administered to the patient by syringe injection. 
The material is absorbed, carried by the circulation to the kidneys, 
and by them filtered from the blood and excreted. The time required 
before excretion begins, and the quantity eliminated within a given 
time, vary in direct proportion to the renal activity. That is to say, 
the more efficient the renal excretory power, the more rapid and more 
pronounced will be the excretion. Conversely, the more impairment 
of renal function, the greater the delay of the onset of elimination, 
and the more will the quantity excreted be reduced. The correlation 
of urinary obstruction and renal function in conditions such as ad- 
vanced prostatic hypertrophy must always be taken into account, since 
large amounts of residual urine may influence all function tests. Under 
these circumstances the true functional sufficiency of the kidneys can- 
not be ascertained until a few days after the relief of the urinary 
obstruction. 



FUNCTIONAL EFFICIENCY OF THE KIDNEYS. 331 

The numerous potential sources of error in interpreting the results 
of renal function tests have undoubtedly been responsible for much of 
the disfavor with which they have been regarded in the past. The 
most prolific of these is easily avoided. The intravenous adminis- 
tration is a matter of paramount importance and cannot be too strongly 
urged, as the agents are thus introduced directly into the economy. 
Their elimination is consequently rapid and the deductions therefrom 
are fairly exact. The absorption after subcutaneous or intramuscular 
injections depends upon capillary proximity to the site of injection, 
local circulatory activity, the thickness of the walls of the blood-vessels, 
blood density and osmosis, all of which vary materially in different 
individuals. This lack of uniformity of absorption in patients adds 
an element of error easily obviated by intravenous injection, which 
reduces to the infinitesimal those sources of error that abound after 
subcutaneous or intramuscular injection. By intravenous injection 
the dosage is accurate, the selected agent enters the circulation un- 
changed, and its advent into the renal tissue is prompt and certain, 
none of which advantages can be claimed for the other methods. Sub- 
cutaneous and intramuscular injections of some of the anilin dyes are 
particularly painful, and this unpleasant feature is also avoided by 
the intravenous route. In fact, the intravenous administration offers 
so many advantages over the other methods, and the observations 
become so much more reliable in consequence, that it should be the 
only one employed under ordinary circumstances. No untoward re- 
sults have been noted in an experience of several hundred injections, 
and the technic is simple. The sole prerequisites for absolute safety 
are the use of distilled water only in the preparation of the solutions, 
and perfect sterility. 

Cryoscopy of the urine and the methylene-blue test are almost 
obsolete in this country, and some of the others which have been ad- 
vocated at various times have not found much favor. 

Estimation of the twenty-four hour urea output is often of great im- 
portance, but the nitrogenous content of the urine depends upon so 
many qualifying factors other than the process of elimination that 
these must always be taken into consideration when viewing such fig- 
ures as an index of renal function. The significance of the twenty- 
four hour urea output is greatly augmented by a determination of 
the non-protein nitrogen, urea nitrogen, creatinin, and uric acid in the 
blood, and when the urine urea is below the minimum normal of 
20 gm. (300 grains), this should always be done as a complemen- 
tary examination. To elucidate this, a concrete example may be 
cited. Assuming the twenty-four hour urea to be 17 gm., if the nitro- 



332 URINARY ANALYSIS AND DIAGNOSIS. 

genous elements of the blood are normal in quantity (non-protein 
nitrogen, 25 to 30 mg.; urea nitrogen, 12 to 15 mg.; creatinin, 1 to 2 
mg.; and uric acid, 2 to 3 mg., in each 100 c.c. of blood), the decrease 
is probably due to restricted ingestion of proteins, or some other 
negative factor. On the other hand, if the hematogenous con- 
stituents are distinctly increased beyond normal limits, the retention 
of excrementitious materials in abnormally large amounts clearly in- 
dicates perversion of metabolism or diminished renal permeability. 
For convenience, the urea nitrogen may be taken as a fairly reliable 
guide in the majority of instances. If this is found in excess of 20 
mg., the prognosis is proportionately serious, except in cases of 
chronic parenchymatous nephritis, in which the nitrogenous retention 
is often low. 

Phenolsulphonephthalein Test. — This test, which is probably 
as accurate and delicate as any for the determination of the func- 
tional activity of the kidneys, was introduced by Rountree and 
Geraghty, and at the present time is the most popular and widely used 
of all. The solution is prepared as follows: 0.6 gm. of phenolsulpho- 

2 

nephthalein and 0.84 c.c. of a ^- NaOH solution (8 per cent) are added 

to sufficient 0.75 per cent NaCl solution to make 100 c.c. Each c.c. of 
this solution represents six milligrams of the dye. The preparation, 
when ready for injection, is a monosodium salt, which is red in color 
and slightly irritating locally. Hence, two or three drops more of a 

2 

^x NaOH solution may be added until the color is changed to a Bor- 
deaux red, when it becomes non-irritating. The dose is one cubic 
centimeter. Ampules of this preparation, ready for use, can now be 
purchased in the market, but these usually contain more than 1 c.c. 
Caution must therefore be exercised to inject 1 c.c. only, and not the 
entire contents of the ampule. 

The technic is the following: Twenty or thirty minutes before 
applying the test the patient is directed to drink 300 to 500 c.c. of 
water, to insure a free urinary secretion. Otherwise, delayed time of 
excretion may be due to lack of secretion. Under aseptic precau- 
tions a catheter is passed and the bladder completely emptied. One 
cubic centimeter of the solution (0.006 gm. of phenolsulphonephtha- 
lein) is injected intramuscularly or intravenously, the latter method 
being preferred, and the time noted. The end of the catheter, which 
has been left in situ, is placed in a test tube containing a drop of 25 
per cent NaOH solution, and the time of appearance of the first pinkish 
tinge noted. The catheter is then withdrawn and the patient directed 



FUNCTIONAL EFFICIENCY OF THE KIDNEYS. 333 

to rest. If the dye has been injected intravenously, the contents of 
the bladder are collected at the end of half an hour, either by catheter 
or voiding, preferably the former. If intramuscularly, the urine is 
collected at the end of one hour, and again in another receptacle at 
the end of the second hour. In prostatic or other cases where there is 
urinary obstruction, it is best to leave the first catheter in place 
continuously until the end of the observation, it being closed at the 
time of the first appearance of the drug in the urine until it is necessary 
to empty the bladder for the collection of the specimen to be tested. 

The half hour, or each hour, specimen is then carefully measured, 
the specific gravity taken, and the urea may be estimated if desired. 
It is then diluted with water to 200 c.c, and 10 c.c. of a 5 per cent solu- 
tion of NaOH added, which makes the urine decidedly alkaline and 
brings out the purple-red color. It is again further diluted to 1000 
c.c, and a small quantity placed in the cup of a Duboscq, Sargent, or 
Hellige colorimeter, for comparison with the standard solution in the 
other cup.* Readings are then taken to estimate accurately the per- 
centage amount of the drug eliminated. The color is not affected by 
the ordinary urinary pigments nor by pus. 

In normal cases it has been found that the time of the first appear- 
ance of phenolsulphonephthalein in the urine after intramuscular in- 
jection is from 6 to 11 minutes, and that 35 to 60 per cent is eliminated 
in the first hour, and 20 to 25 per cent additional in the second hour 
(60 to 85 per cent in all). From these figures it is apparent that the 
limit of error allowed for normal cases is about 25 per cent, which is 
entirely too wide a latitude. When intravenous injection is practiced, 
the first appearance of the dye occurs in from 4 to 6 minutes, and 30 
to 40 per cent is excreted by the kidneys in half an hour, in normal cases. 
These figures are far more reliable. 

The elimination of the drug does not necessarily run parallel to the 
excretion of water. The smaller the amount of water in normal cases, 
the greater the concentration of the dye. It is immaterial, however, 
so far as the excretion of the drug is concerned, whether the urinary 
output is 50 or 400 or more cubic centimeters. 

The phenolsulphonephthalein test, performed in this manner, can 
be utilized by the general practitioner, and no special instruments 
other than a colorimeter are required. He can thus determine in 
general the metabolic capabilities of his patient and gain a reasonably 
definite idea of the renal efficiency. It is important to remember that 

* The Duboscq and Sargent colorimeters are expensive, while the Hellige is 
comparatively inexpensive, and gives very satisfactory results. Utmost accuracy, 
simplicity and rapidity of the test are claimed for this instrument. 



334 URINARY ANALYSIS AND DIAGNOSIS. 

allowance must always be made for possible unilateral disease with 
compensatory hyperactivity of the other kidney, the sum total of 
which may closely approximate the normal. The absolute amount of 
work, as well as the relative proportion, done by each kidney can be 
ascertained by obtaining the urine from each kidney separately. To 
differentiate the two sides, not only is the use of a cystoscope neces- 
sary, but a ureteral catheterizing instrument is required, so that the 
urine may be collected from each side and the phenolsulphonephthalein 
content of the specimens estimated. The normal for one side is of 
course one half the normal for both. 

In pathological cases the renal permeability for this drug is lowered, 
the decrease varying in direct proportion to the extent and intensity 
of the disease. The greater the impairment of function, the greater 
will be the delay in the onset of excretion, and the less will be the 
quantity eliminated. 

The advantages of the phenolsulphonephthalein test are the sim- 
plicity of technic, the non-toxic and non-irritating properties of the 
drug, the complete elimination by the kidneys, the fact that no in- 
struments of precision other than a colorimeter are necessary, and the 
colorimetric method permits of fairly accurate quantitative observa- 
tions. Its disadvantages are that the differentiation of the two sides 
requires the use of a catheterizing cystoscope, ureteral catheters, and a 
trained cystoscopist. Many cases of acute inflammation, ureteral 
stricture, etc., will be encountered where ureteral catheterism is 
not feasible, even if available. It also often inhibits renal function, 
thereby influencing the test. 

Indigo-carmine Test. — Many surgeons regard this test as su- 
perior to the phenolsulphonephthalein for the diagnosis of surgical 
lesions of the kidney, since a difference in excretion on the two sides is 
recognized more easily. It is often referred to as chromo-cystoscopy 
because, as the test is usually performed, conclusions are drawn from 
cystoscopic visualization of the ejection of colored urine from the ure- 
teric orifices. Whereas in the phenolsulphonephthalein test the per- 
centage excreted within a given time is taken as the index of renal 
efficiency, after indigo-carmine injection the time of its first appearance, 
the intensity of the color, and the force and character of the ejected 
streams, as observed through the cystoscope, are considered more 
significant. Practically the same knowledge can be acquired with a 
simple examining cystoscope in a few minutes in this manner that 
would require bilateral ureteral catheterization and a longer period of 
waiting after phenolsulphonephthalein injection. 

The technic is the following: 0.04 gm. of indigo-carmine, in either 



FUNCTIONAL EFFICIENCY OF THE KIDNEYS. 335 

powder or tablet form, is dissolved in 10 c.c. of freshly distilled water, 
which makes a 0.4 per cent solution. This is injected intravenously, 
and the time noted. The normal kidney will excrete highly blue 
colored urine in from 3 to 6 minutes. The ejection may commence in 
less time than this, which indicates especially good renal function. 
In the experience of the writer, the shortest time within which the dye 
made its appearance was 1 minute and 20 seconds. Immedi- 
ately following the indigo-carmine injection the cystoscope is intro- 
duced into the distended bladder and the ureteric orifices carefully 
watched. As a rule, the ejection appears as a forcible dark blue jet, 
but in some cases of disease the traces of color may be faint or the 
urine may dribble from the ureteric opening. The following phe- 
nomena are suggestive but by no means positive : 

Synchronous bilateral delay suggests parenchymatous or interstitial 
nephritis. 

Marked delay on one side, with unusually early elimination from 
the other, indicates disease in the first instance and compensatory 
hyperactivity in the second. 

EUmination beginning on one side from 8 to 12 minutes after the 
intravenous injection, although within normal time limits from the 
other, suggests chronic pyelitis on the side delayed. 

Elimination not beginning until from 12 to 18 minutes is indica- 
tion of partial ureteral obstruction or moderate impairment of renal 
function. 

If after 20 minutes observation no ejection of indigo-carmine is 
noted, practically complete ureteral obstruction or serious disease of 
the kidney or ureter may be safely assumed. 

Dribbling instead of spurting from the ureteric orifice means loss of 
tissue tone or partial obstruction of ureter or renal pelvis. 

The advantages of this test are the simplicity of technic, the ra- 
pidity with which the results may be obtained, the easy differentiation 
of the two sides without the possible inhibition of renal function some- 
times occasioned by ureteral catheterism, and the fact that no color- 
imeter is necessary. Its sole disadvantages are that cystoscopy is 
essential, and it does not estimate the patient's metabolic capabilities 
as well as the phenolsulphonephthalein. Frequently, however, the 
two tests may be combined to advantage. For example, in unilateral 
renal tuberculosis the indigo-carmine will quickly demonstrate which 
kidney is affected and the compensatory hyperactivity of the other, 
if such hyperactivity exists. To ascertain more exactly the patient's 
ability to tolerate proposed operative procedures, a phenolsulpho- 
nephthalein test may then be done. If the percentage of phenol- 



336 URINARY ANALYSIS AND DIAGNOSIS. 

sulphonephthalein is decidedly below normal, the surgeon is thus 
forewarned. 

The urine may be collected at the end of certain periods of time 
after indigo-carmine injection and the percentage eliminated estimated 
by means of a colorimeter, as in the phenolsulphonephthalein test, but 
for quantitative determination this method offers no advantages over 
the phenolsulphonephthalein and is not quite as reliable. 

Phloridzin Test. — After the subcutaneous injection of 1 to 5 
cgm. of phloridzin, a glucosid sugar will appear in the urine in from 
15 to 30 minutes, and continue for 2 or 3 hours. As some observers 
state that the excretion is never uniform, even in health, the results 
may be decidedly misleading when the test is performed in this manner. 
This method has now been superseded by the following improved 
technic : 

A tablet consisting of 0.01 gm. phloridzin and 0.02 gm. NaCl is 
placed in the barrel of an all glass Luer syringe, the syringe and needle 
are assembled, and 2 c.c. of hot distilled water drawn up into the 
syringe. Solution of the tablet is effected by shaking, and when 
complete, the intravenous injection is made immediately. The details 
of this technic are important, since phloridzin is but sparingly soluble 
in cold water, although freely so in hot. It also rapidly crystallizes 
out on cooling of the solution, hence the injection must be made with- 
out loss of time. This injection of 2 c.c. of 0.5 per cent phloridzin 
insures a satisfactory duration and intensity of induced glycosuria, 
and is free from danger and untoward sequelae. 

To determine the total renal permeability, the bladder is cathe- 
terized and several test tubes are prepared, each containing a few cubic 
centimeters of heated Fehling's solution. The catheter is left in situ 
and the intravenous injection given. In three minutes urine is per- 
mitted to flow from the catheter into one of the test tubes containing 
Fehling's solution, and each two minutes thereafter into other test 
tubes similarly prepared, until typical sugar reaction takes place. 
When the renal function is normal, sugar appears in from 4 to 7 min- 
utes. If no glycosuria occurs until 15 minutes or more have elapsed, 
impairment of renal function is indicated. The delay increases in 
direct proportion to the advancement of destruction of kidney pa- 
renchyma. The sugar reaction usually reaches its acme during the 
first 15 minutes, is somewhat reduced during the next 15 minute 
period, and becomes very low or disappears soon thereafter. 

To differentiate the two sides, both ureters are catheterized before 
the phloridzin intravenous injection, and the urine is collected in 
separate test tubes containing Fehling's solution. Observations may 



FUNCTIONAL EFFICIENCY OF THE KIDNEYS. 337 

be repeated on each side every 2 minutes, as before. 

Occasionally in pathologic cases the glycosuria may persist for an 
unusually long period. Some clinicians have endeavored to determine 
the percentage and absolute quantity of sugar excreted, but such 
quantitative estimations under these circumstances are unreliable and 
of little practical value. In general, it may be said that delayed ap- 
pearance of phloridzin sugar is rarely observed in healthy individuals, 
while pronounced delay of excretion denotes impairment of renal 
efficiency. 

This test offers no striking advantages over the phenolsulphoneph- 
thalein and indigo-carmine tests, for there is nothing that can be 
learned from the intravenous injection of phloridzin that cannot be 
ascertained more easily and with less trouble by one of the other 
methods. Its evident disadvantages are the limited solubility of 
phloridzin, its tendency to precipitate on cooling of the solution, and 
the cumbersome technic that is necessary. Notwithstanding these 
facts, this test has a certain number of enthusiastic adherents among 
urologists at the present time. 

Methylene Blue Test. — This is the oldest of all the dye tests 
and was formerly somewhat extensively employed by foreign observers. 
It never became popular in this country, probably because of its mani- 
fest unreliability. The latter may have been due in part to the fact 
that the drug was always injected subcutaneously or intramuscularly, 
and before the importance of intravenous technic was acknowledged 
it had been supplanted by other tests. 

When 0.5 gm. of methylene blue is injected subcutaneously or into 
the gluteal muscles, the substance appears in the urine partly in its 
original character and partly in the form of a colorless chromogen, which 
may be converted into the pigment by adding acetic acid and heating. 
The dye usually appears in the urine in about 30 minutes, but both the 
time of onset of excretion and the amount eliminated may vary con- 
siderably in normal kidneys. It reaches its maximum in about 4 
hours, and continues to be eliminated for a number of hours thereafter. 
The observations to be taken into account are the time of the first ap- 
pearance of color in the urine, the intensity of the pigment, and the 
duration of elimination. If the kidneys are diseased, the excretion 
of methylene blue is delayed, sometimes for 2 hours or longer. This 
retardation is not nearly as marked in chronic parenchymatous as in 
chronic interstitial nephritis. The color may be estimated by the 
colorimetric method, but this test is by no means exact. 

The sole advantage of the methylene blue test is that instruments 
of precision are unnecessary. Its disadvantages are numerous: the 

22 



338 URINARY ANALYSIS AND DIAGNOSIS. 

physical properties of methylene blue are partly altered in the body 
before it is eliminated, it requires a comparatively long time for com- 
plete excretion, the rate of excretion is often irregular, and quantita- 
tive estimation or differentiation of the two sides unduly prolongs the 
examination. 

Cryoscopy. — The physio-chemical procedure of determining the 
freezing point of a solution, such as the urine and blood, is based upon 
the observations of Raoult that the freezing point varies in inverse 
proportion to the number of molecules it contains. The molecular 
weight is of no consequence in estimating the alteration, which cor- 
responds to the number of molecules it comprises. The greater the 
number of molecules, the lower the freezing point. Electrolytes, how- 
ever, depress according to the number of ions; they therefore cause a 
much greater depression than non-conducting substances. The 
freezing point, or cryoscopic index, of a solution is often designated by 
the Greek symbol A, and is compared with that of distilled water, 
which freezes at 0° C. The freezing point of normal 24-hour urine 
varies from —0.9° C. to —2.6° C. The freezing point of normal blood 
is fairly constant, being —0.56° C. to —0.58° C, although it may be 
reduced independently of renal insufficiency in some cases of typhoid 
fever, diabetes, and other conditions. If there is a pathologic process 
of the kidneys, interfering with their proper functional activity, the 
freezing point of the urine rises, because the total number of molecules 
is diminished. At the same time the freezing point of the blood is cor- 
respondingly lowered, because of the higher molecular concentration 
produced by the retention of excrementitious products. Cryoscopy 
of the blood is of value in determining the absolute or total renal func- 
tion, especially when estimation of the relative function of the two 
kidneys through ureter catheterization is contraindicated, and at the 
present time is deemed far superior to urine cryoscopy, since its appli- 
cation does not disturb the urinary apparatus. In cryoscopy of the 
urine the renal secretion must be measured for a certain period of 
time, so that allowances may be made for reflex polyuria and other 
causes of disturbance of urinary output. Blood cryoscopy is probably 
the most valuable and reliable function test in determining the 
prognosis in chronic nephritis, and for this purpose it should be widely 
used. It possesses no peculiar virtues, however, in the diagnosis of 
surgical lesions of the kidneys. Cryoscopy of the urine has now been 
practically discarded as a prognostic factor, probably because it is 
quite evident that the retention of excrementitious material in the 
blood is of more consequence and clinical significance than the estima- 
tion of what is excreted through the kidneys. But it may be used as 






FUNCTIONAL EFFICIENCY OF THE KIDNEYS. 339 

corroborative evidence when other methods are also employed. If the 
cryoscopic index of the blood is much below —0.60° C, nephrectomy is 
contraindicated, as the patient is likely to die from uremia. Para- 
doxical as it may seem, in many cases of existing uremia the freezing 
point of the blood is not lowered. This may be explained by hydre- 
mia or the albuminoid character of the uremic toxin. 

The apparatus most frequently employed for freezing point deter- 
minations is Beckmann's cryoscope, although a number of modifi- 
cations have been described. It consists of a flat bottomed glass 
cylinder for the blood, urine, or other fluid to be tested, into which dips 
the bulb of a very delicate thermometer, graduated to one-one-hun- 
dredth of a degree. The thermometer is rigidly suspended in its proper 
position, its bulb touching only the fluid in which it is immersed, and 
enters the cylinder through a perforated rubber stopper. A platinum 
wire, intended for stirring the material so that it will be of equal tem- 
perature throughout, is also introduced through another hole in the 
same stopper. Outside of the first glass cylinder is a second one, con- 
taining alcohol or glycerine, which is pressed down into a large glass 
jar containing the freezing mixture of salt and ice. Ten to twenty 
cubic centimeters of distilled water are placed in the first glass cylinder 
and continuously and regularly stirred. At the same time the freezing 
mixture is stirred with a heavy wire. The distilled water gradually 
cools and as it approaches the freezing point, the mercury in the ther- 
mometer falls rapidly. Then it stops, and suddenly rises to a high 
point, where it hesitates momentarily. This is the true freezing point 
of the distilled water under the existing physical conditions. After 
the freezing point of the distilled water has been taken, the water is 
decanted and replaced with the fluid to be tested. The entire technic 
is repeated and the freezing point again noted. The difference 
between the freezing point of distilled water and that of the fluid 
tested will be the index of its molecular concentration, or freezing 
point. 

In testing blood or urine, 10 to 20 c.c. should be used. The blood 
is obtained by venous aspiration and may be used whole or as de- 
fibrinated plasma. The urine is best taken from a 24-hour specimen. 

Experimental Polyuria. — This test was introduced by Albarran 
and is based on an estimation of the renal functional activity as com- 
pared with the amount and quality of the urine excreted. The urea 
content, freezing point, and microscopical features are emphasized. 
After preliminary fasting, the patient is given a pint of mineral water 
to drink, ureteral catheters are passed, and three separate specimens 
are collected from each side at the end of half an hour, one hour, and 



340 (RINARY ANALYSIS AND DIAGNOSIS. 

an hour and a half. There are so many possible sources of error that 
the conclusions drawn from the observations made are extremely 
indefinite. 

Electric Conductivity of the Urine. — This method is a com- 
plicated procedure and of very slight practical value. It is based 
upon the fact that the power of a solution to conduct a current varies 
with its molecular concentration. 

Toxicity Test. — In health, urine is poisonous when injected into 
rabbits and other animals, although its toxicity varies even under 
normal conditions. In the process of disease, its toxic content may be 
increased or diminished. In fevers, such as the exanthemata, it is 
usually increased, while in nephritis it is diminished, and the urine is 
claimed to be non-poisonous when the renal lesion is extensive. The 
practical value of this test is insignificant. 

All these function tests are quite free from unpleasant sequela? 
and serious complications. Catheterization of ureters, however, is 
not an innocuous procedure, especially if the catheters are left in situ 
for any considerable length of time, for it may cause a temporary 
hematuria, and occasionally precipitates a renal colic. When speci- 
mens are collected through ureteral catheters for quantitative estima- 
tions, the catheters should be of sufficient size to effectively plug the 
ureters. Otherwise leakage of urine may occur along the catheter, 
thus admitting a source of error. The quantity of urine, its cryoscopic 
index, the amount of urea, and one of the dye tests may be combined in 
a single examination. But as the color tests interfere with the excre- 
tion of sugar, the phloridzin test should not be done at the same time. 
The chief value of these functional tests is diagnostic. In addition to 
determining the renal efficiency in derangements of metabolism and 
diseases of the uro-genital tract, they also serve to differentiate an 
extra-renal mass from one that exists in the kidney, and will often 
demonstrate whether or not conditions of coma are renal in origin. 
While one or more function tests alone may not permit of correct judg- 
ment in saiy particular case, they are often of great assistance in com- 
pleting the clinical picture. 



APPENDIX. 

When many urine examinations are made, it is a good plan to have a 
printed blank for such examinations, which, or a copy of which, is filed 
away for future reference. As in the great majority of cases only the 
more important chemical tests are necessary, these alone should be in- 
corporated in the blank, leaving space for any special examination to be 
made in certain cases. The following blank can be used for all purposes: 

Report on Examination of Urine. 

Patient 

From Dr 

Received 

Examined 

Physical and Chemical Examination. 

Passed 

Total in twenty-four hours 

Reaction 

Color 

Odor 

Sediment 

Specific gravity '. 

Urea 

Urates 

Phosphates 

Sulphates 

Chlorides , 

Carbonates. . 

Albumin 

Sugar 

Acetone 

Diacetic acid 

Bile 

Indican 

Blood 

Other chemical elements 

Total solids 

Microscopical Examination. 
Crystalline and amorphous sediments 

Red blood-corpuscles 

Pus-corpuscles 

341 



342 APPENDIX. 

Epithelia : 

Convoluted tubules of kidney 

Straight collecting tubules of kidney 

Pelvis of kidney 

Ureter 

Bladder 

Urethra 

Prostate 

Seminal vesicles 

Vagina 

Other epithelia 

Tube casts 

Pseudo-casts 

Connective-tissue shreds 

Mucus 

Micro-organisms 

Spermatozoa 

Other features 

Diagnosis 

Remarks 

In filling out the blank the numbers of the different microscopical 
elements should be stated, and the following terms may be used: 

None. 

Very few. 

Few. 

Few to moderate. 

Moderate. 

Fairly numerous. 

Numerous. 

Very numerous. 

Whenever albumin and sugar are present, the approximate per- 
centage amounts should, if possible, be stated. When this cannot 
be done, the following terms, especially for albumin, may be used: 

Faint trace. 

Trace. 

More than trace. 

Small amount. 

Moderate amount. 

Large amount. 

Very large amount. 

These terms may also be employed to determine the amounts of 
bile and other chemical elements. For indican and acetone the terms 



APPENDIX. 343 

slight excess; slight to moderate excess; moderate excess and heavy 
excess are indicated. 

Lists of Apparatus and Reagents Required for Urinary Analysis. 

In the ordinary chemical and microscopical examination of urine 
the apparatus and reagents required are not numerous, though they 
vary with the character and extent of the examinations desired. In 
the following lists all apparatus and reagents mentioned in the preced- 
ing pages are enumerated, many, however, being required only for 
more or less detailed work, such as is not carried out in routine analyses 
by practitioners, but only in more completely equipped laboratories. 
The more important ones in the first two lists are enumerated first. It 
is easy for the individual worker to select those required by him from 
these lists. 

Apparatus. 

Microscope with three lenses and two eyepieces, giving a magnifying power of 
between 50 and 1,000 diameters. 

Centrifuge, either hand, water power or electric. 

Centrifuge tubes, graduated and non -graduated. 

Alcohol lamp. 

Asbestos filtering fibre. 

Camel's hair brushes, small. 

Conical glasses. 

Cover glasses and slides. 

Cover glass forceps. 

Doremus' Ureometer or Hinds' modification. 

Droppers with rubber nipples. 

Dropping bottles. 

Einhorn's Saccharometer. 

Esbach's Albuminometer. 

Filter paper. 

Glass or porcelain dishes, small. 

Glass funnels, different sizes. 

Glass graduates, 5, 10, 25, 50, 100, 500, and 1,000 c.c. 

Glass pipettes, plain and graduated, the latter 5, 10, 25, and 50 c.c. 

Glass rods. 

Litmus paper, blue and red. 

Platinum rods, wire in glass handle. 

Reagent bottles with glass stoppers, various sizes. 

Ruhemann's Uricometer. 

Scale with weights. 

Sedimentation glass or Spaeth's sedimentation glass. 

Test tubes, two or three dozen. 

Test tube brushes with sponge end. 

Test tube holder. 



344 APPENDIX, 

Test tube rack. 

Teasing needles and spatulas. 

Urinometer, preferably Squibb 's. 

Urinometer tube with fluted contours. 

Washing bottle. 

Watch glasses. 

Beakers, thin glass. 

Bunsen burner with tubing. 

Burettes, 50 c.c. each, graduated in tenths of a cubic centimetre. 

Colorimeter, Duboscq, Sargent or Hellige. 

Distilling flasks. 

Erlenmeyer flasks. 

Filter and burette stand. 

Flasks, plain, 250 and 500 c.c. 

Horismascope. 

Incubator. 

Mohr-Westphal balance. 

Polariscope. 

Porcelain evaporating dishes. 

Saxe's Urinopyknometer. 

Thermometers. 

Tripods. 

Water bath, copper, fitted with rings. 

Liquid Reagents. 
Acid, Acetic, c.p. 

Acetic, glacial. 

Carbolic, 5 per cent solution. 

Hydrochloric, c.p., also 2 or 3 per cent solution in 95 per cent alcohol. 

Nitric, c.p., also 25 per cent aqueous solution. 

Phosphoric, 3 per cent solution. 

Sulphuric, 20 per cent solution. 
Aether, sulphuric. 

Alcohol, 60 per cent, 95 per cen + and absolute. 
Ammonia water, dilute. 
Ammonium chloride, sat. sol. 

Barium chloride solution (Barium chlo. 4, HC1 1, Distilled water, 16). 
Barium chloride, standard solution (Cryst. Barium chlo. 30.54, Distilled 
water, 1,000). 

Benedict's solutions, for glucose. 
Bromine, pure. 

Bromine, Rice's solution (Bromine, 30, Potass, bromid, 30, Distilled water, 
240). 

Carbon disulphide. 

Chloroform. 

Cochineal tincture. 

Distilled water. 

Esbach's solution (Picric acid, 1, Citric acid, 2, Distilled water, 100). 

Fehling's solutions (Copper sulphate, and alkaline tartrate). 



APPENDIX. 345 

Ferric chloride, 10 per cent solution. 

Glycerine. 

Gram's solution (Iodine, 1, Potassium iodide, 2, Distilled water, 300). 

Hydrogen peroxide. 

Magnesian fluid (Magnesium sulphate, 1, Ammonium chloride, 1, Distilled 
water, 8, Ammonia water, 1). 

Magnesium sulphate, sat. solution. 

Nitrate of silver solution (1 to 8). 

Nitrate of silver, standard solution (29.075 fused silver nitrate, Distilled 
water, 1,000). 

Obermayer's reagent (HC1, c.p., 500, Ferric chloride, 1). 

Potassium chromate, neutral, sat. aqueous solution. 

Potassium ferrocyanide, 5 and 10 per cent and saturated solutions. 

Potassium hydroxide, 10 per cent and sat. solutions. 

Potassium nitrite, 1 per cent solution. 

Potassium permanganate, 0.5 per cent solution. 

Potassium sulphate solution (Pot. sul. 21.778, Distilled water, 1,000). 

Ruhemann's Iodine solution (Iodine, 0.5, Potassium iodide, 1.25, Absolute 
alcohol, 7.5, Glycerine, 5, Distilled water, q.s., 100). 

Sodium acetate solution (Sod. acet. 100, Distilled water, 900, then add 30 per 
cent acetic acid sol. 100). 

Sodium hydroxide, 10 per cent and sat. solutions. 

Sodium hydroxide, 100 to 250 distilled water. 

Uranium nitrate, 5 per cent solution. 

Uranium nitrate or acetate, standard solution (35.5 of the salt to 1,000 distilled 
water). 

Acid, Boric, c.p. 

Hydrochloric, decinormal solution. 

Nitrous, c.p. 

Picric, 10 per cent and saturated solutions. 

Phosphotungstic, 10 per cent solution. 

Sulpho-salicylic, 20 per cent and saturated solutions. 
Amyl alcohol. 
Ammonium hj^droxide. 
Ammonium sulphate, saturated solution. 
Anilin oil. 

Copper sulphate, 10 per cent solution. 

Diazo reagent (Sulphanilic acid 0.1, HC1 5, Distilled water 100). 
Formaldehyde, 40 per cent solution. 

Haines' solution (Copper sulph. 2, Distilled water, 16, Glycerine, 16, Pot. 
Hydr. 160). 

Haines' solution, modified (Copper sulph. 5, Glycerine, 280, Pot. Hydr. 20, 
Distilled water to 1,000). 

Lead acetate, 20 per cent solution. 
Lugol's solution (see Gram's solution). 
Methyl orange, 0.5 per cent solution. 
Oil of turpentine. 
Sodium acetate, 40 per cent solution. 

carbonate, 0.25 per cent solution. 



346 



APPENDIX. 



Sodium chloride, sat. solution. 

hydroxide, decinormal solution (4 gm. in litre). 

nitrite, 0.5 per cent aqueous solution. 
Spiegler's reagent (Mercuric chloride, 10, Succinic acid, 20, Sod. chlor. 20, 
Distilled water, 500). 

Thymol, 10 per cent alcoholic solution. 

Tincture of Guaiacum. 

Tincture of Iodine. 

Toluene. 

Zinc chloride, 5 per cent alcoholic solution. 



Staining Reagents for Bacteria. 

Bismarck brown, 1 or 2 per cent aqueous solution. 

Fuchsin, carbolic acid solution (Fuchsia, 1, Absolute alcohol, 10, Carbolic 
acid, 5 per cent aqueous sol. 90). 

Gentian violet solution (Con. alcoh. gent, violet sol. 10, Carbolic acid, 5 per 
cent aqueous sol. 90). 

Methylene blue solution (Con. alcoh. methyl blue sol. 30, 0.01 per cent caustic 
potash 100). 

Solid Reagents. 



Acid, Boric. 

Acid, Citric. 

Acid, Picric. 

Acid, Succinic. 

Ammonium chloride. 

Ammonium sulphate. 

Bismarck brown. 

Bismuth subnitrate. 

Calcium hypochlorite. 

Chromic acid. 

Copper sulphate. 

Ferric chloride. 

Fuchsin. 

Gentian violet. 

Indigo-carmine. 

Lead acetate. 

Lead acetate, tribasic. 

Lead carbonate, powdered. 

Magnesium sulphate. 

Mercuric chloride. 

Mercuric chromate. 

Methylene blue. 

Orcin. 

Para-amido-aceto-phenone. 



Phenolsulphonephthalein . 

Phenylhydrazin hydrochlorate. 

Phloridzin. 

Phosphotungstic acid, crystalline. 

Potassium bromate. 

Potassium chlorate. 

Potassium chromate. 

Potassium ferrocyanide. 

Potassium hydroxide. 

Potassium iodide. 

Potassium nitrite. 

Potassium oxalate. 

Potassium permanganate. 

Resorcin. 

Sodium acetate. 

Sodium carbonate. 

Sodium chloride. 

Sodium hydroxide. 

Sodium nitro-prusside. 

Sodium nitrite. 

Sulphanilic acid. 

Sulpho-salicylic acid. 

Thymol. 

Urease. 



INDEX 



Abbe condenser, 89 

Abscess of kidney, 214, 246 

Abscess of pelvis of kidney, 250 

Abscess of prostate gland, 306 

Accidental albuminuria, 49 

Acetic acid in urine, 40 

Acetic acid test for albumin, 50 

Aceto-acetic acid, 75 

Acetone, 74 

Acetone bodies, 72 

Acid-intoxication, 72 

Acid sediment in fermentation, 113 

Acid sediments, 93 

Acid sodium phosphate, 13, 42 

Acidity, degree of, 13 

Acidosis, 72 

Actinomyces, 186 

Actinomyces in bladder, 300 

Actinomycosis, 186 

Acute abscess of kidney, 249 

Acute catarrhal cystitis, 278 

Acute catarrhal nephritis, 221 

Acute croupous nephritis, 230 

Acute interstitial nephritis, 221 

Acute parenchymatous exacerbations, 

245 
Acute parenchymatous hemorrhagic 

nephritis, 233 
Acute parenchimatous nephritis, 230 
Acute prostatitis, 305 
Acute suppurative nephritis, 249 
Acute suppurative prostatitis, 306 
Acute suppurative p3 r elitis, 250 
Acute ulcerative C3'stitis, 285 
Acute urethritis, 303 
Acute vaginitis, 322 
Adenin, 36 

Advantages of centrifuge, 87 
Afferent vessels of glomerulus, 5 
Air-bubbles, 200 
Albumin, 48 

Albumin, quantitative tests for, 53 
Albumin, removal of, 56 



Albumin, tests for, 50 

Albuminometer, 54 

Albuminous substances, 48 

Albuminuria, 48 

Albuminuria, accidental, 49 

Albuminuria, alimentary, 49 

Albuminuria, cyclic, 49 

Albuminuria, functional, 49 

Albuminuria, of adolescence, 49 

Albuminuria, orthostatic, 49 

Albuminuria, postural, 49 

Albuminuria, renal, 49 

Albuminuria, true, 49 

Albumoses. 48, 57 

Alimentary albuminuria, 49 

Alimentary glycosuria, 60 

Alkaline change of acid urine, 114 

Alkaline methylene-blue solution, 178 

Alkaline sediments, 93, 107 

Alkaline phosphates, 41 

Alkaline tide, 14 

Alkapton, 82 

Alkaptonuria, 82 

Allantoin, 38 

Alloxan, 34 

Alloxantin, 34 

Alloxur bases, 36 

Alloxyproteic acid, 38, 44 

Almen's guaiacum test for hsemoglobin, 

81 
Amidopurin, 36 
Amino-acids, 37 
Ammonia, 32 
Ammonia coefficient, 32 
Ammonio-magnesian phosphates, 42, 

107 
Ammonium carbonate, 45 
Ammonium purpurate, 34 
Ammonium urate, 112 
Ammonium urate in statu nascenti, 100 
Amoeboid changes of pus corpuscles, 

127 
Amorphous sediments, 93 



347 



348 



INDEX 



Amorphous simple phosphates, 110 

Amount of solids, 16 

Amount of urine, normal, 15 

Amount of urine, pathological, 20 

Amphoteric reaction, 13 

Amyloid corpuscles of prostate gland, 
141 

Amyloid degeneration of kidney, 214, 
239 

Amyloid disease of kidney, 239 

Anatomical structure of kidney, 210 

Aniline color, 178 

Aniline water, 179, 183 

Aniline water fuchsin solution, 183 

Aniline water gentian violet solution, 
179 

Animal inoculations, 185 

Animal parasites, 187 

Anomalies of secretion, 257 

Antiseptic substances, use of, 88 

Anuria, 20 

Apparatus, list of, 343 

Appearance of urine in cystitis, 278 

Appearance of urine in malignant tu- 
mors of kidney, 271 

Appendix, 341 
' Arched tubule, 2 

Arnold's test for diacetic acid, 76 

Aromatic oxyacids in urine, 40 

Aromatic sulphates, 44 

Arterial arches, 5 

Ascaris lumbricoides, 191 

Ascaris lumbricoides in bladder, 300 

Ascitic fluid, 181 

Aspergilli, 174 

Atrophy of kidney, 157, 214, 240 

Bacillus coli communis, 186 
Bacillus subtilis, 177 
Bacillus ureae, 176 
►_ Bacteria, development of, in urine, 18 
Bacterial casts, 172 
Bacterium termo, 176 
Bacterium ureae, 176 
Bacteriuria, 173, 277 
Bartholinian gland epithelia, 146 
Basidia, 174 

Beckman's cryoscope, 339 
Bence-Jones albumose, 58 
Benedict's quantitative test for sugar, 67 



Benedict's test for sugar, 64 

Beta-hydroxybutyric acid, 76 

Beta-oxybutyric acid, 76 

Bial's orcin test for pentoses, 70 

Bile acids, 80 

Bile pigments, 79 

Bilharzia haematobia, 189 

Bilharziasis, 189 

Bilicyanin, 79 

Bilifuscin, 79 

Bilihumin, 79 

Biliprasin, 79 

Bilirubin, 79, 118 

Biliverdin, 79 

Bismarck brown solution, 180 

Biuret reaction for albumin, 52 

Black granules after injection of silver 

salts, 119 
Bladder, cancer of, 296 
Bladder, diseases of, 276 
Bladder epithelia, 133 
Bladder, inflammations of, 276 
Bladder, papilloma of, 292 
Bladder, parasites in, 300 
Bladder, sarcoma of, 296 
Bladder, tumors of, 292 
Blank for urine examination, 341 
Blood-casts, 163 
Blood-clots, 123 
Blood-corpuscles, 121 
Blood-serum agar, 181 
Boiling test for haemoglobin, 81 
Bottger's test for sugar, 65 
Bowman, capsule of, 1 
Bowman, views of, 6 
Brick-dust sediment, 20, 95 
Bright's disease, 209 
Budding of yeast fungi, 175 
Butyric acid in urine, 40 

Cadaverin, 82 

Calcium carbonate, 114 

Calcium carbonate concretions, 120 

Calcium oxalate, 40, 100 

Calcium oxalate concretions, 119 

Calcium phosphates, 110 

Calcium sulphate, 107 

Calculi, 119 

Calyx of kidney, 2 

Cammidge's reaction, 70 



IXDEX 



349 



Cancer of bladder, 296 

Cancer of kidney, 275 

Cancer pearls, 300 

Cane sugar, 70 

Capsule of Bowman, 1 

Carbamic acid, 16 

Carbamide, 26 

Carbohydrates, 60 

Carbolic acid fuchsin solution, 183 

Carbolic acid gentian violet solution, 

179 
Carbonates, 45 
Carcinoma of bladder, 296 
Carnin, 36 

Casts, 158. See also Tubular casts. 
Casts, bacterial, 172 
Casts, cholesterin, 172 
Casts, coloring of, 162 
Casts, false, 170 
Casts, fat, 172 
Casts, fibrin, 163, 172 
Casts, formation of, 158, 213 
Casts from seminal tubules, 169 
Casts, haemoglobin, 163, 172 
Casts in acute nephritis, 159 
Caste in chronic nephritis, 159 
Casts in subacute nephritis, 160 
Casts, pigment, 172 
Casts, prognostic value of, 160 
Casts, pseudo-, 170 
Casts, pus, 172 
Casts, sizes of, 160 
Casts, sodium urate, 170 
Casts, urate, 170 
Catarrhal cystitis, 278 
Catarrhal cystitis, acute, 278 
Catarrhal cystitis, chronic, 282 
Catarrhal nephritis, 216 
Catarrhal nephritis, acute, 221 
Catarrhal, nephritis, chronic, 221 
Catarrhal nephritis, pathological 

changes in, 212 
Catarrhal pyelitis, 225 
Catarrhal vaginitis, 321 
Caudate epithelia, 132 
Cauliflower growth of bladder, 296 
Causes of anomalies of secretion, 257 
Causes of catarrhal nephritis, 216 
Causes of chyluria, 267 
Causes of congestion of kidney, 215 



Causes of croupous nephritis, 226 

Causes of cystitis, 276 

Causes of haemoglobinuria, 262 

Causes of hyperaemia of kidney, 215 

Causes of prostatitis, 304 

Causes of suppurative nephritis, 246 

Cellulose, 198 

Centrifugal analysis, 46 

Centrifugal method for albumin, 55 

Centrifuge, use of, 86 

Cercomonas urinarius, 192 

Cervical epithelia, 146 

Cervicitis, 327 

Changes in urine upon standing, 18, 86 

Changes of epithelia, 132 

Chemical examination, 13 

Chemical sediments, 93 

Chloride of ammonium, 40 

Chloride of potassium, 40 

Chloride of sodium, 40 

Chlorides, 40 

Chlorophyl globules, 203 

Cholesterin, 82, 116 

Cholesterin casts, 172 

Choletelin, 79 

Choluria, 80 

Chromic acid for preservation of sedi- 
ment, 88 

Chromogens, 17, 39 

Chronic abscess of pelvis of kidney, 253 

Chronic catarrhal cystitis, 282 

Chronic catarrhal nephritis, 221 

Chronic croupous nephritis, 234 

Chronic interstitial nephritis, 221 

Chronic parenchymatous nephritis, 234 

Chronic parenchymatous nephritis 
with acute parenchymatous exacer- 
bation, 245 

Chronic prostatitis, 306 

Chronic suppurative nephritis, 249 

Chronic ulcerative cystitis, 286 

Chronic urethritis, 303 

Chronic vaginitis, 321 

Chyluria, 82, 115, 191, 267 

Ciliated epithelia from ejaculatory 
ducts, 141 

Ciliated epithelia from mucosa uteri, 
147 

Ciliated pus-corpuscles, 128 

Cirrhosis of kidney, 157, 213, 225 



350 



INDEX 



Classification of nephritis, 209 

Clay water sediment, 20, 99 

Clinical symptoms of abscess of kidney, 
249 

Clinical symptoms of anomalies of 
secretion, 257 

Clinical symptoms of catarrhal neph- 
ritis, 217 

Clinical symptoms of croupous neph- 
ritis, 229 

Clinical symptoms of cystitis, 277 

Clinical symptoms of interstitial neph- 
ritis, 217 

Clinical symptoms of lithsemia, 257 

Clinical symptoms of malignant tumors 
of kidney, 271 

Clinical symptoms of oxaluria, 102, 257 

Clinical symptoms of parenchymatous 
nephritis, 229 

Clinical symptoms of prostatitis, 304 

Clinical symptoms of spermatocystitis, 
315 

Clinical symptoms of suppurative ne- 
phritis, 249 

Clinical symptoms of tumors of bladder, 
292 

Clinical symptoms of tumors of kidney, 
241 

Coefficient of Haeser, 23 

Coefficient of Haines, 23 

Coefficient of Long, 23 

Colloid corpuscles of prostate gland, 141 

Color of urine, normal, 14 

Color of urine, pathological, 18 

Color variations, 19 

Colorimeters, 333 

Coloring matter of blood, 80 

Coloring matters of urine, 17, 38, 75 

Coloring of casts, 162 

Coloring of specimens, 177 

Columnar epithelia, 131 

Comparative sizes of pus-corpuscles and 
epithelia, 137 

Complete triple phosphates, 108 

Composition of normal urine, 17 

Concentrated alcoholic fuchsin solution. 
178 

Concretions, 119 

Concretions, prostatic, 141 

Concretions, spermatic, 142 



Congestion of kidney, 215 

Conidia, 173 

Conjugate sulphates, 44 

Connective tissue, 151 

Connective tissue in atroohy of kidney, 
157 

Connective tissue in cancer, 156 

Connective tissue in cirrhosis of kidney. 
157 

Connective tissue in hemorrhage, 154 

Connective tissue in hypertrophy of 
prostate gland, 156 

Connective tissue in intense inflamma- 
tion, 157 

Connective tissue in masturbation, 154 

Connective tissue in papilloma, 155 

Connective tissue in sarcoma, 156 

Connective tissue in stricture of ure- 
thra, 156 

Connective tissue in suppuration, 153 

Connective tissue in traumatism, 154 

Connective tissue in tumors, 155 

Connective tissue in ulceration, 153 

Consistency, normal, of urine, 15 

Constituents of normal urine, 16, 24 

Convoluted tubules, epithelia from, 136 

Cork, 200 

Corn-starch, 197 

Cornification in cancer of bladder, 300 

Cortical substance of kidney, 4 

Cotton fibres, 193 

Creatin, 37 

Creatinin, 37, 103 

Cresol, 38 

Croupous nephritis, 226 

Croupous nephritis, pathological 
changes in ; 213 

Cryoscopy, 338 

Crystalline sediments, 93 

Cuboidal epithelia, 131 

Cultivation of gonococci, 181 

Cultivation of tubercle bacilli, 185 

Culture media, 181 

Cyclic albuminuria, 49 

Cylindrical epithelia, 131 

Cylindroids, 149, 169 

Cystic degeneration of kidney, 214, 240 

Cystin, 82, 103 

Cystin concretions, 120 

Cystinuria, 82 



INDEX 



351 



Cystitis, 276 

Cystitis, catarrhal, 278 

Cystitis, causes of, 276 

Cystitis, clinical symptoms of, 277 

Cystitis, suppurative, 286 

Cystitis, ulcerative, 285 

Damalic acid, 16 
Damaluric acid, 16 
Decolorizing of specimens, 183 
Desquamative nephritis, 216 
Detection of acetone, 74 
Detection of acetone bodies, 72 
Detection of albumin, 50 
Detection of albumoses, 57 
Detection of alkaline phosphates, 43 
Detection of bile pigments, 80 
Detection of carbonates, 46 
Detection of chlorides, 41 
Detection of diacetic acid, 75 
Detection of earthy phosphates, 42 
Detection of fibrin, 59 
Detection of globulin, 57 
Detection of gonococci, 177, 178 
Detection of haemoglobin, 81 
Detection of indican, 77 
Detection of lactose, 69 
Detection of levulose, 69 
Detection of maltose, 70 
Detection of mucin, 59 
Detection of nucleo-albumin, 59 
Detection of pentoses, 70 
Detection of peptones, 58 
Detection of phosphates, 42 
Detection of sugar, 61 
Detection of sulphates, 45 
Detection of tubercle bacilli, 177, 181 
Detection of uric acid, 34 
Detection of urobilin, 39 
Determination of freezing-point, 338 
Determination of functional efficiency 

of kidney, 329 
Determination of reaction, 14 
Determination of solids, 22 
Determination of total acidity, 14 
Deutero-albumoses ; 57 
Development of microorganisms, 86 
Dextrose, 60 
Di-amino acid, 37 
Diabetes mellitus, 60 



Diabetic acetonuria, 74 
Diacetic acid, 75 

Diagnosis of atrophy of kidney, 240 
Diagnosis of cancer of bladder, 296 
Diagnosis of cancer of kidney, 275 
Diagnosis of catarrhal cystitis, 281 
Diagnosis of catarrhal nephritis, 218 
Diagnosis of cervicitis, 327 
Diagnosis of chyluria, 267 
Diagnosis of cirrhosis of kidney, 225 
Diagnosis of congestion of kidney, 215 
Diagnosis of croupous nephritis, 230 
Diagnosis of endometritis, 327 
Diagnosis of epithelia, 131 
Diagnosis of fistula, 203 
Diagnosis of haemoglobinuria, 262 
Diagnosis of hyperaemia of kidney, 215 
Diagnosis of interstitial nephritis, 218 
Diagnosis of lithaemia, 257 
Diagnosis of nephritis, 218 
Diagnosis of oxaluria, 261 
Diagnosis of papilloma of bladder, 292 
Diagnosis of parasites in bladder, 300 
Diagnosis of parenchymatous nephritis, 

230 
Diagnosis of pericystitis, 291 
Diagnosis of prostatitis, 304 
Diagnosis of pus corpuscles, 129 
Diagnosis of pyelitis, 226 
Diagnosis of pyelo-nephritis, 221 
Diagnosis of renal tuberculosis, 253 
Diagnosis of sarcoma of bladder, 296 
Diagnosis of sarcoma of kidney, 272 
Diagnosis of spermatocystitis, 315 
Diagnosis of spermatorrhoea, 312 
Diagnosis of suppurative cystitis, 286 
Diagnosis of suppurative nephritis, 246 
Diagnosis of suppurative pyelitis, 250 
Diagnosis of ulcerative cystitis, 285 
Diagnosis of urethritis, 303 
Diagnosis of vaginitis, 321 
Diagram of kidney, 3 
Diamins, 82 

Diaphragms of microscope, 90 
Diazo reaction, 78 
Diffuse inflammation of kidney, 211 
Digested muscle fibres, 203 
Diseases of bladder, 276 
Diseases of kidney and pelvis of kidney, 

209 



352 



INDEX 



Diseases of sexual organs, 303 
Disodium phosphate, 13 
Distal convoluted tubule, 2 
Distoma haematobium, 189 
Distoma haematobium in bladder, 300 
Donne's test for pus, 129 
Doremus' ureometer, 28, 29 
Drugs giving diazo reaction, 79 

Earthy phosphates, 41 

Echinococci, 188 

Echinococci in bladder, 300 

Efferent vessel of glomerulus, 6 

Ehrlich's diazo reaction, 78 

Einhorn's fermentation saccharometer, 
67 

Ejaculatory duct epithelia, 141 

Electric conductivity test, 340 

Ellerman and Erlandsen's method for 
detection of tubercle bacilli, 182 

Endogenous new-formations in epi- 
thelia, 135 

Endometritis, 327 

Entozoa, 187 

Epidermal scales,. 132 

Epiguanin, 36 

Episarcin, 36 

Epithelia, 131 

Epithelia, changes of, in urine, 132 

Epithelia, columnar, 131 

Epithelia common to both sexes, 133 

Epithelia, cuboidal, 131 

Epithelia, cylindrical, 131 

Epithelia, flat, 131 

Epithelia from Bartholinian gland, 146 

Epithelia from bladder, 133 

Epithelia from cervix uteri, 146 

Epithelia from convoluted tubules of 
kidney, 136 

Epithelia from ducts of prostate gland, 
140 

Epithelia from ejaculatory ducts, 141 

Epithelia from mucosa uteri, 147 

Epithelia from pelvis of kidney, 135 

Epithelia from prostate gland, 139 

Epithelia from prostatic portion of 
urethra, 140 

Epithelia from seminal vesicles, 141 

Epithelia from straight collecting tu- 
bules of kidney, 138 



Epithelia from ureters, 136 
Epithelia from urethra, 139 
Epithelia from urine of female, 145 
Epithelia from urine of male, 139 
Epithelia from uriniferous tubules, 136 
Epithelia from vagina, 145 
Epithelia, horny, 132 
Epithelia in normal urine, 131 
Epithelia in posterior urethritis, 140 
Epithelia, simple, 131 
Epithelia, sizes of, 132 
Epithelia, squamous, 131 
Epithelia, stratified, 131 
Epithelial casts, 162 
Epithelioma of bladder, 300 
Esbach's albuminometer, 54 
Essential haematuria, 125 
Estimation of albumin by centrifugal 

analysis, 55 
Estimation of chlorides by centrifugal 

analysis, 46 
Estimation of earthy phosphates, 44 
Estimation of phosphates by centrifugal 

analysis, 47 
Estimation of sulphates by centrifugal 

analysis, 47 
Estimation of total nitrogen, 25 
Estimation of total phosphoric acid, 43 
Estimation of total sulphates, 45 
Estimation of uric acid, 34 
Ethereal sulphates, 38, 44 
Experimental polyuria, 339 
Extraneous fat-globules, 200 
Extraneous matters, 193 
Exudate, nature of, in inflammation, 

211 
Eyepieces of microscope, 89 

Faeces, 203 

False casts, 170 

Fat, 115 

Fat-casts, 172 

Fat-globules, 115 

Fat-granules in epithelia, 135 

Fat-granules in pus-corpuscles, 128 

Fatty acids, 40 

Fatty casts, 166 

Fatty degeneration of kidney, 212, 214, 

234 
Fatty matters ? 82 



INDEX 



353 



Feather, 195 

Features found in urine in abscess of 
kidney, 249 

Features found in urine in acute inter- 
stitial nephritis, 221 

Features found in urine in acute paren- 
chymatous nephritis, 230 

Features found in urine in atrophy of 
kidney, 240 

Features found in urine in cancer of 
bladder, 299 

Features found in urine in catarrhal 
cystitis, 278 

Features found in urine in catarrhal 
nephritis, 217 

Features found in urine in chronic 
interstitial nephritis, 222 

Features found in urine in chronic 
parenchymatous nephritis, 234 

Features found in urine in chyluria, 268 

Features found in urine in cirrhosis of 
kidney, 225- 

Features found in urine in croupous ne- 
phritis, 229 

Features found in urine in cystitis, 278 

Features found in urine in haemoglobin- 
uria, 262 

Features found in urine in hemorrhage 
from pelvis of kidney, 258 

Features found in urine in interstitial 
nephritis, 217 

Features found in urine in lithaemia, 257 

Features found in urine in papilloma of 
bladder, 292 

Features found in urine in parenchyma- 
tous nephritis, 229 

Features found in urine in pericystitis, 
291 

Features found in urine in prostatitis, 
305 

Features found in urine in renal tuber- 
culosis, 253 

Features found in urine in sarcoma of 
bladder, 296 

Features found in urine in sarcoma of 
kidney, 272 

Features found in urine in spermatocys- 
titis, 315 

Features found in urine in subacute 
interstitial nephritis, 222 
23 



Features found in urine in subacute 

parenchymatous nephritis, 234 
Features found in urine in suppurative 

nephritis, 249 
Features found in urine in tuberculosis 

of kidney, 253 
Features found in urine in vaginitis, 321 
Fehleisen's streptococcus, 181 
Fehling's test for sugar, 62, 66 
Fermentation saccharometer, 67 
Fermentation tests for sugar, 66, 67 
Fermentative changes in urine, 114 
Ferments in urine, 17, 40 
Ferrocyanide test for albumin, 52 
Fibres, extraneous, 193 
Fibrin, 48, 59, 122 
Fibrin-casts, 172 
Filaments in urine, 142, 143 
Filaria sanguinis hominis, 190, 267 
Filaria sanguinis in bladder, 300 
Fission-fungi, 176 
Fistula, diagnosis of, 203 
Fittipaldi's test for acetone bodies, 72 
Flaky sediment, 20 
Flat epithelia, 131 
Flaws in glass, 200 
Flocculent sediment, 20 
Fluorin in urine, 46 
Folin's method for total acidity, 14 
Formalin, influence of, on indican tests, 

78 
Formalin method for determination of 

ammonia, 32 
Formic acid in urine, 40 
Frommer's test for acetone, 75 
Fruit-bearer in mould fungi, 174 
Fruit sugar, 69 

Fuchsin, alcoholic solution, 178 
Fuchsin, aniline-water solution, 183 
Fuchsin, carbolic-acid solution, 183 
Fuchsin, water}' solution, 178 
Functional albuminuria, 49 
Functional efficiency of kidney, 329 
Fungi, 173 

Gabbett's method for tubercle bacilli, 

184 
Gaseous constituents of urine, 17 
General considerations on microscopical 

examination, 85 



354 



INDEX 



General remarks, 8 
Gentian violet solution, 179 
Gerhardt's reaction for diacetic acid, 75 
Ghosts or hydropic red blood corpuscles, 

122 
Gleet-threads, 142 
Globulin, 56 
Glomerulitis, 212 
Glomerulo-nephritis, 212 
Glomerulus of kidney, 1 
Glucose, 60 

Glycerophosphoric acid, 16, 42 
Glycosuria, 60 
Glycuronic acid, 70 
Gmelin's test for bile pigments, 80 
Gonococci, 178 
Gonococci, detection of, 177 
Gonorrhoea, acute, 178 
Gonorrhoea, chronic, 180 
Gonorrhceal cystitis, 277 
Gram's method, 179 
Gram's solution, 179 
Granular casts, 163 
Granular sediment, 20 
Granulation of pus-corpuscles, 127 
Grape sugar, 60 
Gravel, 119 

Gravimetric method of albumin, 56 
Guanin, 36 
Gunning's test for acetone, 75 

Haematoblasts, 122 

Haematoidin, 117 

Haematoidin crystals in pus-corpuscles, 

128 
Haematoporphyrin, 17, 39, 81 
Haematuria, 80, 121 
Haematuria, origin of, 124 
Haemoglobin, 48, 59, 80 
Haemoglobin casts, 163, 172 
Haemoglobinuria, 80, 262 
Haeser's coefficient, 23 
Haines' coefficient, 23 
Haines' modified test for sugar, 63 
Haines' test for sugar, 62 
Hairs of plants, 202 
Halliburton's table for color variations, 

19 
Hammarsten's table, 16 
Hart's method for /3-oxybutyric acid, 76 



Hay bacillus, 177 

Hayem's liquid for preservation, 89 

Heat tests for albumin, 50, 51 

Heidenhain, experiments of, 6 

Heintz's method for uric acid, 36 

Heller's test for albumin, 51 

Heller's test for haemoglobin, 81 

Hemi-albumose, 57 

Hemorrhage from genito-urinary or- 
gans 124, 154 

Hemorrhage from kidney, 124, 216 

Hemorrhage from pelvis of kidney, 
258 

Hemorrhage from seminal vesicles, 316 

Hemp-seed calculi, 119 

Henle's loop, 2 

Hetero-albumose, 57 

Heteroxanthin, 36 

Hinds' modification of Doremus' ureo- 
meter, 30 

Hippuric acid, 37, 105 

Histology of kidney, 1 

Histon, 48, 59 

Hob-nail kidney, 225 

Homogentisic acid, 82 

Horismascope, 53 

Human hairs, 194 

Hyaline casts, 160 

Hydrocele agar-agar, 181 

Hydrogen dioxide in urine, 46 

Hydrometer, 20 

Hydropic pus-corpuscles, 127 

Hydropic red blood corpuscles, 122 

Hydro quinon-acetic acid, 82 

Hydruria, 20 

Hyperaemia of kidney, 215 

Hypertrophy of prostate gland, 156, 
311 

Hyphae, 174 

Hyphomycetes, 173 

Hypobromite method for urea, 28 

Hypoxanthin, 36 

Idiopathic renal haematuria, 125 
Illumination in using microscope, 90 
Incomplete triple phosphates, 109 
Indican, 77 
Indigo, 118 

Indico-carmine test, 334 
Indigo concretions, 119 



INDEX 



355 



Indol, 38 

Indoxyl, 38 

Indoxyl potassium sulphate, 77 

Inflammation, character of, 211 

Inflammation, diffuse, 211 

Inflammations of bladder, 276 

Inflammations of kidney, 209 

Inflammations of pelvis of kidney, 209 
225 

Inflammatory corpuscles, 126, 212 

Influence of potassium iodide and pre- 
servatives on indican tests, 78 

Inorganic constituents 16, 40 

Inorganic sulphates, 44 

Intercalated tubule, 2 

Interlobar arteries, 5 

Interlobular arteries, 5 

Interlobular veins, 6 

Interstitial nephritis, 216 

Interstitial nephritis, acute, 221 

Interstitial nephritis, chronic, 221 

Interstitial nephritis, clinical symp- 
toms of, 217 

Interstitial nephritis, pathological 
changes in, 212 

Introductory, 1 

Iodine reaction of pus corpuscles, 129, 
130 

Iodoform test for acetone, 75 

Ionic theory, 13 

Iris diaphragms of microscope, 90 

Iron in urine, 46 

Irritation of kidney, 212 

Isomaltose, 69 

Jackson-Taylor's test for acetone, 74 
Jaffe's test for creatinin, 37 
Jaffe's test for indican, 77 
Jolles' test for indican, 78 

Kidney, abscess of, 214, 246 

Kidney, amyloid disease of, 239 

Kidney, anatomical structure of, 210 

Kidney, anomalies of secretion of, 257 

Kidney, atrophy of, 240 

Kidney, cancer of, 275 

Kidney, catarrhal inflammation of, 216 

Kidney, cirrhosis of, 225 

Kidney, congestion of, 215 

Kidney, cortical substance of, 4 



Kidney, croupous inflammation of, 226 

Kidney diseases, 209 

Kidney epithelia, 136 

Kidney, fatty degeneration of, 234 

Kidney, functional efficiency of, 329 

Kidney, histology of, 1 

Kidney, hyperemia of, 215 

Kidney inflammations, 209 

Kidney, interstitial inflammation of, 

216 
Kidney, large white, 234 
Kidney, malignant tumors of; 271 
Kidney, medullary substance of, 4 
Kidney, parenchymatous inflammation 

of, 226 
Kidney, sarcoma of, 271 
Kidney, secretory structure of, 6 
Kidney, suppurative inflammation of, 

246 
Kidney, tuberculosis of, 253 
Kidney, vascular supply of, 5 
Kidney, waxy degeneration of, 239 
Kjeldahl's estimation of total nitrogen, 

25 
Knop's hypobromide method, 28 
Koch's method of coloring tubercle 

bacilli, 183 
Kwilecki's albumin test, 54 

Labyrinth, 3 

Lactic acid in urine, 16 

Lactose, 69 

Lange's test for acetone, 74 

Large white kidney, 214, 234 

Legal's test for acetone, 74 

Lenses of microscope, 89 

Lenticular epithelia, 132 

Leptothrix threads, 177 

Leucin, 38, 82, 106 

Leucocytes, 122, 126 

Leucorrhcea, 145 

Levulose, 69 

Lieben's iodoform test for acetone, 75 

Linen fibres, 194 

Lipaciduria, 40 

Lipase in urine, 40 

Lipliawski's modification of Arnold's 

test for diacetic acid, 76 
Lipuria, 82, 116 
Liquid reagents, list of, 344 



356 



INDEX 



List of apparatus and reagents, 343 
Litheemia, 98, 257 

Lceffler's alkaline methylene blue solu- 
tion, 178 
Lcefner's blood serum, 181 
Long's coefficient, 23 
Lycopodium, 197 

Magnesian fluid, 43 

Magnesium phosphate, 115 

Magnifying powers, 91 

Malignant tumors of kidney, 271 

Malpighian corpuscle, 1 

Maltose, 69 

Margaric acid, 116, 203 

Marshall's clinical method for urea 
determination, 31 

Materia peccans, 99 

Medullary cancer of bladder, 296, 300 

Medullary rays, 3 

Medullary substance of kidney, 4 

Melanin, 81, 119 

Melanogen, 82 

Method of using microscope, 90 

Methylene blue solution, 178 

Methylene blue test, 337 

Methylmercaptan, 16 

Methylxanthin, 36 

Micrococci gonorrhoeae, 178 

Micrococci in endocarditis, 181 

Micrococci in septic processes, 181 

Micrococcus ureae, 176 

Micro-organisms, 173 

Micro-organisms, non-pathogenic, 173 

Micro-organisms, pathogenic, 177 

Microscope, 89 

Microscopical features in acute abscess 
of pelvis of kidney or acute suppura- 
tive pyelitis, 255 

Microscopical features in acute abscess 
of prostate gland, 307 

Microscopical features in acute catar- 
rhal cystitis, 279 

Microscopical features in acute hemor- 
rhagic parenchymatous or croupous 
nephritis with pyelitis and catarrhal 
cystitis, 235 

Microscopical features in acute inter- 
stitial nephritis (acute catarrhal 
pyelo-nephritis) and cystitis, 219 



Microscopical features in acute paren- 
chymatous or croupous nephritis 
with pyelitis and catarrhal cystitis, 
231 

Microscopical features in acute ulcera- 
tive cystitis, 287 

Microscopical features in chronic catar- 
rhal cystitis, 283 

Microscopical features in chronic catar- 
rhal vaginitis, 323 

Microscopical features in chronic inter- 
stitial nephritis (catarrhal pyelo- 
nephritis) and cystitis, 223 

Microscopical features in chronic par- 
enchymatous or croupous nephritis 
with fatty degeneration of kidney, 
accompanying pyelitis and catarrhal 
cystitis, 241 

Microscopical features in chronic paren- 
chymatous or croupous nephritis 
with fatty and waxy degeneration 
of kidney, accompanying pyelitis, 
243 

Microscopical features in chronic par- 
enchymatous or croupous nephritis 
with fatty and waxy degeneration of 
kidney, and acute hemorrhagic croup- 
ous exacerbation, pyelitis, and catar- 
rhal cystitis, 247 

Microscopical features in chronic pros- 
tatitis, 309 

Microscopical features in chronic pros- 
tatitis with hypertrophy of prostate 
gland, 313 

Microscopical features in chronic sper- 
matocystitis or seminal vesiculitis, 
317 

Microscopical features in chronic sup- 
purative nephritis with pyelitis, 251 

Microscopical features in chronic ulcera- 
tive cystitis, 289 

Microscopical features in chyluria, ca- 
tarrhal cystitis, 269 

Microscopical features in cirrhosis of 
kidney with chronic catarrhal cystitis, 
227 

Microscopical features in hsemoglobin- 
uria, acute hemorrhagic croupous or 
parenchymatous nephritis with catar- 
rhal pyelitis, 265 



INDEX 



357 



Microscopical features in hemorrhage 

from bladder, due to papilloma of 

bladder, 297 
Microscopical features in hemorrhage 

from pelvis of kidney, due to uric acid 

calculus, 263 
Microscopical features in hemorrhage 

from seminal vesicles with acute 

prostatitis, 319 
Microscopical features in lithaemia 

with subacute pyelitis and catarrhal 

cystitis, 259 
Microscopical features in pericystitis 

due to parametritis, 293 
Microscopical features in sarcoma of 

kidney, chronic pyelitis, and catar- 
rhal cystitis, 273 
Microscopical features in subacute 

parenchymatous or croupous ne- 
phritis, with pyelitis and catarrhal 

cystitis, 237 
Microscopical features in ulcerative 

vaginitis, 325 
Microscopical features in villous cancer 

of bladder, 301 
Milk sugar, 69 
Mineral sulphates, 44 
Mitchell's test for acetone bodies, 

73 
Mixed casts, 169 
Mohr's titration method for chlorides, 

41 
Mohr-Westphal balance, 21 
Mono-amino acid, 37 
Monosodium phosphate, 13 
Moore-Heller test for sugar, 61 
Morbus Brightii, 209 
Morner and Sjoqvist's method for urea, 

30 
Mould-fungi, 173 
Mounting of sediment; 88 
Mucin, 59 
Mucus, 149 
Mucus-casts, 149, 169 
Mucus-corpuscles, 149 
Mucus-threads, 149 
Mulberry calculi, 119 
Murexide test for uric acid, 34 
Muscle fibres, 203 
Mycelia, 174 



Nature of haematuria, 124 

Nephritis, acute catarrhal, 221 

Nephritis, acute croupous, 230 

Nephritis, acute hemorrhagic parenchy- 
matous, 233 

Nephritis, acute interstitial, 221 

Nephritis, acute parenchymatous, 230 

Nephritis, catarrhal, 216 

Nephritis, chronic interstitial or catar- 
rhal, 221 

Nephritis, chronic parenchymatous 
croupous, 234 

Nephritis, chronic parenchymatous, 
with acute exacerbation, 245 

Nephritis, chronic parenchymatous, 
with fatty degeneration of kidney, 
234 

Nephritis, chronic parenchymatous, 
with waxy degeneration of kidney, 
240 

Nephritis, classification of, 209 

Nephritis, croupous, 226 

Nephritis, cystic degeneration of, 240 

Nephritis, desquamative, 216 

Nephritis, interstitial, 216 

Nephritis, parenchymatous, 226 

Nephritis, pathological changes in, 212 

Nephritis, pathology of, 210 

Nephritis, subacute interstitial, 222 

Nephritis, subacute parenchymatous, 
234 

Nephritis, suppurative, 246 

Nerves of kidney, 6 

Neutral sulphates, 44 

Nitric acid test for albumin, 51 

Nitrogen, total, 24 

Nitrogen, total, estimation of, 25 

Nitrogenous constituents, 25 

Nitrogenous partition of urine, 25 

Non-pathogenic microorganisms, 173 

Non-tropical chyluria, 267 

Normal constituents of urine, 16, 24 

Normal faeces, 203 

Normal urine, 13 

Nubecula, 17, 85 

Nuclei in pus-corpuscles, 128 

Nuclein bases, 36 

Nucleo-albumin, 48, 59 

Nucleo-histon, 48, 59 

Nylander's test for sugar, 65 



358 



INDEX 



Obermayer's simplified test for indican, 

78 
Obermayer's test for indican, 77 
Objectives of microscope, 89 
Oculars of microscope, 89 
Odor of urine, 15 
Oidium lactis, 173 
Oil-globules, 200 
Oliguria, 20 

Organic constituents, 16, 24 
Organic sulphur, 44 
Orthostatic albuminuria, 49 
Oxalic acid, 16, 39 
Oxaluria, 102, 261 
Oxaluric acid, 16 
Oxyacids, aromatic, 40 
Oxyproteic acid, 38, 44 
Oxyuris vermicularis, 192 
Oxyuris vermicularis in bladder, 300 

Papillary cancer of bladder, 296 

Papillary ducts, 1 

Papilloma of bladder, 292 

Parasites, animal, 187 

Parasites in bladder, 300 

Paraxanthin, 36 

Parenchymatous nephritis, 226 

Parenchymatous nephritis, pathological 
changes in, 213 

Parke's table for normal constituents, 
17 

Pathogenic schizomycetes, 177 

Pathological changes in atrophy of 
kidney, 214 

Pathological changes in catarrhal in- 
flammations, 212 

Pathological changes in cirrhosis of kid- 
ney, 213 

Pathological changes in croupous in- 
flammations, 213 

Pathological changes in inflammations 
of kidney, 212 

Pathological changes in interstitial in- 
flammation, 212 

Pathological changes in parenchyma- 
tous inflammation, 213 

Pathological changes in suppurative in- 
flammation, 214 

Pathological urine, 18 

Pathology of nephritis, 210 



Pelvic epithelia, 135 

Pelvis of kidney, hemorrhage from, 258 

Penicillium glaucum, 174 

Pentoses, 70 

Pepsin, 40 

Peptone, 48, 57 

Pericystitis, 291 

Perirenal abscess, 250 

Permanent microscopical specimens, 89 

Phenol, 38 

Phenolsulphonephthalein test, 332 

Phenylglucosazon, 65 

Phenylhydrazin test for sugar, 65 

Phenylic acid, 16 

Phloridzin test, 336 

Phosphates, 41 

Phosphates, significance of, 111 

Phosphates, simple, 110 

Phosphates, triple, 107 

Phosphatic concretions, 119 

Phosphatic diabetes, 42 

Phosphaturia, 42, 112 

Phosphoric acid anhydride, 41 

Phosphoric acid, estimation of, 43 

Phosphoric acid, excretion of, 41 

Physical and chemical properties, 13 

Physiological glycosuria, 60 

Picric acid test for albumin, 52 

Pigment casts, 172 

Pigment granules after injection of 
silver salts, 119 

Pigment granules in pus-corpuscles, 128 

Pigments, 17 

Pin worm, 192 

Pohl's method of globulin, 57 

Pollakiuria, 20 

Polyuria, 20 

Polyuria, experimental, 339 

Posterior urethritis, epithelia in, 140 

Postural albuminuria, 49 

Potassium ferrocyanide test for albu- 
min, 52 

Potassium iodide, influence of, on in- 
dican tests, 78 

Potassium urate, 99 

Preformed sulphates, 44 

Preservation of sediment, 88 

Preservatives, influence of, on indican 
tests, 78 

Production of pus-corpuscles, 212 



INDEX 



359 



Propionic acid in urine, 40 

Prostate gland, epithelia from, 139 

Prostate gland, hypertrophy of, 311 

Prostate gland, inflammation of, 304 

Prostate gland, tuberculosis of, 311 

Prostate gland, tumors of, 312 

Prostatic concretions, 141 

Prostatic epithelia, 139 

Prostatitis, 304 

Proteins, 48 

Proteoses, 57 

Protoalbumose, 57 

Proximal convoluted tubule, 2 

Pseudo-albuminuria, 49 

Pseudo-casts, 170 

Purdy's centrifugal analysis, 46 

Purdy's centrifugal method for albumin, 

55 
Purin bases, 36 
Purin bodies, 36 
Purulent sediment, 20 
Pus, formation of, 214 
Pus-casts, 172 
Pus-corpuscles, 125 
Pus-corpuscles, appearance of, 127 
Pus-corpuscles, derivation of, 126, 128, 

212 
Pus-corpuscles in ammoniacal urine, 127 
Pus-corpuscles, production of, 212 
Putrescin, 82 
Pyelitis calculosa, 261 
Pyelitis, catarrhal, 225 
Pyelitis, suppurative, 250 
Pyelo-nephritis, 221 
Pyknometer, 21 
Pj r ogenous membrane, 215 
Pyo-nephrosis, 246 
Pyrocatechin, 38 
Pyuria, 125, 126 

Quantitative estimation of chlorides, 41 
Quantitative tests for albumin, 53 
Quantitative tests for ammonia, 32 
Quantitative tests for sugar, 66 
Quantitative tests for total phosphoric 

acid, 43 
Quantitative tests for total sulphates, 

45 
Quantitative tests for urea, 28 
Quantitative tests for uric acid, 34 



Quantity of urine, normal, 15 
Quantity of urine, pathological, 20 

Reaction of urine, 13 

Red blood-corpuscles, 121 

Removal of albumin from urine, 56 

Removal of blood from sediment, 123 

Renal albuminuria, 49 

Renal artery, 5 

Renal function tests, 329 

Renal hematuria, 1 24 

Renal haemophilia, 125 1 

Renal tuberculosis, 253 

Report on examination of urine, 341 

Results when urine is boiled, 50 

Rice's solution for urea, 29 

Rice-starch, 197 

Robert's fermentation test for sugar, r 66 

Ropy sediment, 20 

Rosenbach's test for bile pigments, 80 

Ruhemann's uricometer, 35 

Rust particles, 201 

Saccharometer, 67 
Saccharomycetes, 174 
Saccharose, 70 
Salts, 93 

Sarcinae urinse, 176 
Sarcoma of bladder, 296 
Sarcoma of kidney, 271 
Saxe's urinopyknometer, 22 
Scales from moth, 196 
Schizomycetes, 176 
Schizomycetes, pathogenic, 177 
Scratches in cover glass, 200 
Seat worm, 192 
Secondary cystitis, 276 
Secretion, anomalies of, 257 
Secretory structure of kidney, 6 
Sediment, brick-dust, 95 
Sediment, clay water, 99 
Sediment in urine of an athlete, 104 
Sediment, normal, 17, 85 
Sediment, pathological, 20, 86 
Sediment, preservation of, 88 
Sedimentation glass, 85 
Sedimentation tubes, 87 
Sedimentum lateritium, 99 
Selection of urine, 8 
Seminal tubules, casts from, 169 



360 



INDEX 



Seminal vesicles, epithelia from, 141 
Seminal vesicles, hemorrhage from, 

316 
Seminal vesicles, inflammation of, 315 
Seminal vesiculitis, 315 
Serum-albumin, 48 
Serum-globulin, 48 
Shrinkage of kidney, 225 
Significance of pus-corpuscles, 126, 127 
Silicic acid in urine, 46 
Silk fibres, 194 
Simple epithelial fining, 131 
Simple phosphates, 110 
Skatol, 38 
Skatoxyl, 38 

Skatoxyl potassium sulphate, 78 
Smegma, 145 
Smegma bacillus, 182, 185 
Sodium urate, amorphous, 99 
Sodium urate casts, 170 . 
Sodium urate, change of, 100 
Sodium urate, crystalline, 99 
Solid reagents, list of, 346 
Solids, determination of, 22 
Solids in urine, 16 
Solution, aniline water fuchsin, 183 
Solution, Bismarck brown, 180 
Solution, carbolic-acid fuchsin, 183 
Solution, concentrated alcohol fuchsin 

178 
Solution, Gram's, 179 
Solution, Lceffler's alkaline methylene 

blue, 178 
Solution, methylene blue, 178 
Solution, Ziehl-Neelsen's 183 
Source of hemorrhage, 123 
Source of pus-corpuscles, 128 
Sources of epithelia, 131 
Spaeth's sedimentation glass, 85 
Specific gravity, 15 
Specific gravity, determination of, 20 
Sperma, 142 
Sperma crystals, 142 
Spermatic concretions, 142 
Spermatocystitis, 317 
Spermatorrhoea, 142, 312 
Spermatozoa, 142, 315 
Spiegler's test for albumin, 52 
Spiral fibres from air-vessels of plants, 

202 



Sporangium, 174 

Spores, 173, 203 

Sprouting of yeast fungi, 175 

Squamous cancer of bladder, 296 

Squamous epithelia, 131 

Staining reagents for bacteria, list of, 

346 
Staphylococci pyogenes, 176, 181 
Starch-globules, 197 
Star-shaped simple phosphates, 110 
Stellate simple phosphates, 110 
Sterigmata, 174 
Stones, 119 

Straight collecting tubule, 2 
Straight collecting tubules, epithelia 

from, 138 
Stratified epithelia, 131 
Streptococci pyogenes, 176, 181 
Streptococcus of Fehleisen, 181 
Stricture of urethra, 156, 304 
Strongylus gigas, 192 
Strongylus gigas in bladder, 300 
Subacute catarrhal cystitis, 285 
Subacute interstitial nephritis, 222 
Subacute parenchymatous nephritis, 

234 
Subnitrate of bismuth test for sugar, 65 
Substage condensor, 89 
Succinic acid, 16 
Sugar, quantitative tests for, 66 
Sugar, tests for, 61 
Sulphates, 44 
Sulphocyanates, 44 
Sulpho-salicylic acid test for albumin, 

52 
Sulphuretted hydrogen, 82 
Sulphuric acid-methylene blue solution, 

184 
Suppuration, 153 
Suppuration of ureter, 226 
Suppurative cystitis, 286 
Suppurative inflammation of kidney, 

214 
Suppurative nephritis, 246 
Suppurative nephritis, pathological 

changes in, 214 
Suppurative prostatitis, 306 
Suppurative pyelitis, 250 
Surgical kidney, 246 
Symptoms of oxaluria, 102, 257 



INDEX 



361 



Taurilic acid, 16 

Taurine, 16 

Test, cryoscopy, 338 

Test, electric conductivity, 340 

Test, experimental polyuria, 339 

Test for /3-oxybutyric acid, 76 

Test, indigo-carmine, 334 

Test, methylene-blue, 337 

Test, phenolsulpbonephthalein, 332 

Test, phloridzin, 336 

Test, toxicity, 340 

Tests for acetone, 74 

Tests for acetone bodies, 72 

Tests for albumin, 50 

Tests for albumose, 57 

Tests for ammonia, 32 

Tests for bile pigments, 80 

Tests for blood coloring matter, 81 

Tests for carbonates, 46 

Tests for chlorides, 41, 46 

Tests for coloring matters, 80 

Tests for creatinin, 37 

Tests for determination of renal func- 
tion, 329 

Tests for diacetic acid, 75 

Tests for ethereal sulphates, 38 

Tests for fibrin, 59 

Tests for globulin. 57 

Tests for glycuronic acid, 70 

Tests for haemoglobin, 81 

Tests for hippuric acid, 37 

Tests for indican, 77 

Tests for lactose, 69 

Tests for levulose, 69 

Tests for maltose, 69 

Tests for mucin, 59 

Tests for pentoses, 70 

Tests for peptone, 58 

Tests for phosphates, 42, 47 

Tests for pus, 129 

Tests for sugar, 61 

Tests for sulphates. 45, 47 

Tests for urea, 28 

Tests for uric acid, 34 

Tests for urobilin, 39 

Thymol, influence of, on indican tests, 
78 

Total nitrogen, 24 

Toxicity test, 340 

Transitory glycosuria, 60 



Traumatic vaginitis, 322 
Traumatism, 154 
Tri-oxy-purin, 36 
Trichomonas vaginalis, 187 
Triple phosphates, 42, 107 
Trommer's test for sugar, 61 
Tropical chyluria, 267 
True albuminuria, 49 
True casts, 159 
Tsuchiya's albumin test, 55 
Tubercle bacilli, 181 
Tubercle bacilli, appearance of, 184 
Tuberculin injections, 185 
Tuberculosis of kidney, 184, 253 
Tuberculosis of prostate gland, 311 
Tubular casts, 158 
Tubular casts, blood, 163 
Tubular casts, epithelial, 162 
Tubular casts, fatty, 166 
Tubular casts, formation of, 213 
Tubular casts, granular, 163 
Tubular casts, hyaline, 160 
Tubular casts, mixed, 169 
Tubular casts, waxy, 167 
Tubules of Bellini, 2 
Tuft of kidney, 1 
Tumors, 155 
Tumors of bladder, 292 
Tumors of kidney, 271 
Tumors of prostate gland, 312 
Tumors of uterus, 327 
Twenty-four hours' collection, 8 
Typhoid bacilli, 185 
Tyrosin, 38, 82, 106 

Ulceration, 153 

Ulceration in urethra, 304 

Ulceration of ureter, 226 

Ulcerative cystitis, 285 

Ulcerative vaginitis, 322 

Ultzmann's test for bile pigments, 80 

Undetermined nitrogen, 25, 37 

Unorganized sediments, 115 

Unoxidized sulphur, 44 

Urate casts, 170 

Urate concretions, 119 

Urea, 26 

Urea nitrate, 27 

Urea oxalate, 28 

Urea, quantitative test for, 28 



362 



INDEX 



Urease methods for urea, 31 

Ureometer, Doremus', 28 

Ureometer, Hinds' modification, 30 

Ureteral catheterization, 139 

Ureteral epithelia, 136 

Ureteritis, 226 

Urethral epithelia, 139 

Urethral threads, 142 

Urethritis, 303 

Uric acid, 33, 93 

Uric acid casts, 170 

Uric acid, chemical tests, 34 

Uric acid, common form, 94 

Uric acid concretions, 96, 119 

Uric acid diathesis, 96 

Uric acid from highly acid urine, 96 

Uric acid gravel, 97 

Uric acid under microscope, 95 

Uricometer, 35 

Urinary concretions, 119 

Urinary diagnosis, 207 

Urinary hydrometer, 20 

Urinary pigments, 17 

Urine obtained by ureteral catheter, 139 

Uriniferous tubules, 1 

Uriniferous tubules, epithelia from, 136 

Uriniferous tubules, lining of, 2 

Urinometer, 20 

Urinopyknometer, 22 

Urobacillus liquefaciens septicus, 277 

Urobilin, 17, 39, 81 

Urobilinogen, 17, 39 

Urochrome, 17, 39 

Uroerythrin, 17, 39 

Uroferric acid, 44 

Urohsematin, 17, 39 

Uroindican, 17, 77 

Uroleucinic acid, 82 

Use of centrifuge, 86 

Use of antiseptic substances, 88 

Use of microscope, 89 

Uterine epithelia, 147 



Vaginal epithelia, 145 

Vaginitis, 321 

Vaginitis, catarrhal, 321 

Vaginitis, traumatic, 322 

Vaginitis, ulcerative, 322 

Van Slyke and Cullen's method for urea 

determination, 32 
Variations in color, 19 
Varieties of cancer of bladder, 296 
Varieties of nephritis, 211 
Vascular supply of kidney, 5 
Vegetable fibres, 202 
Vegetable matter, 202 
Venous arches, 6 
Villous cancer of bladder, 296 
Virchow's classification of nephritis, 

210 
Vitali's test for pus, 129 
Vogel's color tints, 15 
Volatile acids in urine, 16 
Volatile fatty acids in urine, 40 

Water-fungi, 203 

Watery fuchsin solution, 178 

Waxy casts, 167 

Waxy degeneration of kidney, 212, 214 

239 
Weyl's method for creatinin, 37 
Wheat-starch, 197 
White blood-corpuscles, 122 
Wool fibres, 194 

Xanthin, 35 
Xanthin bases, 36 
Xanthin concretion, 119 

Yeast-fungi, 174 

Ziehl-Neelsen's carbolic acid fuchsin 

solution, 183 
Zooglcea, 176 



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